Glass. Book COPYRIGHT DEPOSIT PRACTICE OF MEDICINE — WHITTAKER - '/ % W A k\ ^ f K /,tf / t'V 1 V Is 3 * 17 Pathogenic Micro-organisms See description on page vi. N THE THEORY AND PEACTICE OF MEDICINE PREPARED FOR STUDENTS AND PRACTITIONERS JAMES T. WHITTAKEE, M.D., LL.D. Professor of the Theory and Practice of Medicine in the Medical College of Ohio; Lecturer on Clinical Medicine at the Good Samaritan Hospital; Fellow of the College of Physicians of Philadelphia; Member of the Association of American Physicians, of the American Academy of Medicine, and of the American Medical Association WITH A CHR0M0-LITHOGRAPHIC PLATE AND THREE HUNDRED ENGRAVINGS WS8 1892 NEW YORK Ns s^> WAS ^€ WILLIAM WOOD & COMPANY 1893 <¥G Copyright by WILLIAM WOOD & COMPANY 18 £3 PRESS OF 5TETT1NER, LAMBERT & CO., 22, 24 & 26 READE ST., NEW YORK. LC Control Number tmp96 028694 THIS BOOK IS DEDICATED (by permission) EOBEET KOCH, MEDICAL PRIVY COUNCILLOR OF PRUSSIA: FOUNDER OF BACTERIOLOGY: WHOSE WORK IS MAKING A SCIENCE OF THE ART OF MEDICINE ; BY BIS FIRST AMERICAN STUDENT '; GEOEGE M. STERNBERG, SURGEON- GENERAL OF THE UNITED STATES ARMY: THE PIONEER IN THE STUDY OF PARASITISM IN THIS COUNTRY BY HIS FRIEND, THE AUTHOR. "As for the truth, it endureth and is always strong ; it liveth and conquereth for ever more." -Esdras I. iv. 38. Pilate saith unto him, What is truth f" -John xviii. 38. :i Appie del vero il dubbio." —Dante, Del Par ad i so, iv. 131. PREFACE. In the preparation of this book the most work has been put upon the infections, as the most frequent and dangerous, at the same time the most preventable, of all diseases ; and in the study of the infec- tions the most space has been devoted to cause and diagnosis, for the reason that a knowledge of the cause establishes prevention, and with the diagnosis develops treatment, except in so far as treatment must still remain wholly sj'mptomatic. Morbid anatomy meets here with but little consideration, and post-mortem revelations are men- tioned only when they may throw a clear light upon the nature and treatment of disease. The practitioner who looks up from the signs and lesions to the cause will entertain more hope of treatment : for the practice of medicine is now not so empirical as the symptoma- tologists claim, or so barren as the pathologists deplore. From this standpoint this book is prepared for the student and practitioner of medicine, but especially for the young physician who, with microscope and test tube, would fit himself for the higher places in his profession. With the most highly appreciated generosity, the Messrs. Win. Wood & Co., Lea Bros. & Co., and W. B. Saunders have per- mitted the author to select, condense, or make use of contributions prepared by him for works recently or just issued by them. These chapters (selections from which constitute perhaps one-twelfth of the present volume), in Wood's " Reference Handbook," Pepper's ''System of Medicine,''" Hare's '"Therapeutics/" Pepper's "Ameri- can Text Book,'' contain accounts more full than may be found in an ordinary text book, whose chief merit must consist in the suc- cinct presentation of the latest facts. The fact that the proof was corrected at a watering place distant from a library will excuse the absence of proper credit from smj figures or statements where it may have been lost in press. A text book must necessarily be full of shortcomings. No one so fully appreciates the vast wealth of knowledge in internal pathology, accumulated through the ages, as he who attempts to encompass it in a book, or so keenly realizes his own poverty as he who attempts to add to the general sum the most inconsiderable mite. J. T. W. Cincinnati, Ohio, September 1st, 1893. PATHOGENIC MICKOOKGANISMS. Chiefly from Original Drawings by Koch and Loffler. EXPLANATION OF PLATE. Fig. 1. Lepra. — Fluid expressed from a nodule, stained with carbol-fuchsin, display- ing bacilli, free and enclosed in large, non-nucleated cells. Fig. 2. Malaria. — Plasmodium Malarias. Protozoa from drop of blood from finger pulp after a chill, stained with methylene blue, displaying large, nucleated white blood corpuscles, smaller non-nucleated red blood corpuscles, free and filled with protozoa; also free protozoa. Figs. 3, 4. Pymmia. — Streptococcus pyogenes and Staphylococcus pyogenes aureus. Fig. 5. Oonorrhcea. — Gonococcus, cover-glass preparation, stained with methylene blue; pus cells filled with gonococci. Fig. 6. Pneumonia. — Diplococcus of pneumonia (Frankel-Weichselbaum), stained by Gram's method; section of alveolus, displaying exudation of cells with diplo- cocci, alone and in chains, in and between the cells. Fig. 7. Charbon. — Milzbrand bacilli, gelatin stick culture; upper stratum fluidified, bacilli as whitish mass at bottom of fluid; displaying two large colonies with numerous radiating outshoots into the substance of the still solid gelatin. Fig. 8. CJiolera. — Stick culture of cholera spirillum in gelatin, four days old ; upper stratum exposed to air, fluidified to characteristic funnel shape ; spirilla in mass at bottom and in neck of funnel. Fig. 9. Typhoid Fever.— Gelatin stick culture of typhoid bacillus, displaying opales- cent, translucent surface. Fig. 10. Tuberculosis. — Pure culture of tubercle bacillus on surface of gelatin in inclined test tube, displaying dry, white scales, natural size. Fig. 11. Cholera. — Gelatin surface culture of cholera spirillum, x 80, displaying irregu- lar border and irregular " broken-glass" surface. The larger colonies, with more sunken border, lie nearer the surface of the gelatin. Fig. 12. Typhoid Fever. — Gelatin surface culture of typhoid bacillus, x 80, displaying dark- brown, sharply- defined border with finely granulated surface; sometimes showing concentric zones. Fig. 13. Glanders. — Bacillus mallei from spleen of field mouse, cover-glass prepa- ration, stained with methylene blue, displaying uncolored regions resembling spores. Fig. 14. Cholera. — Pure culture of cholera spirillum in bouillon, stained with fuch- sin, displaying "comma" bacilli, alone and united in spirals. Fig. 15. Typhoid Fever. — Pure culture of typhoid bacillus in gelatin, displaying short, thick rods as in tissues, and elongated structures in culture. Fig. 16. Tuberculosis. — Tubercle bacillus from sputum, double-stained with aniline- gentian- violet and Bismarck brown. Fig. 17. Dysentery. — Amcebre coli. TABLE OF COXTE'HTS. PART I. GENERAL DISEASES. INFECTIONS-PAEASITES. CHAPTER I. Ectozoa, 3 Animal : Scabies — Pediculi, capitis, pubis, vestirnenti — Acarus folliculo- rum — Pulex — Pulex penetrans— Cimex — Mosquito, etc. Vegetable: Fa- vus— Herpes tonsurans, Eczema marginatum, Onychomycosis — Pityriasis versicolor, Madura Disease, Muscardine, Fly Fungus — Thrush— Lepto- thrix buccalis — Actinomycosis. CHAPTER II. Entozoa, 23 Cysticercus cellulose — Taenia armata, saginata, lata — Taenia echinococ- cus — Multilocular Cysts — Round Worm — Threadworm — Whipworm — Anchylostoma — Trichina spiralis — Filaria, medinensis, sanguinis — Ele- phantiasis — Liver Fluke — Distoma Haematobium. CHAPTER III. Bacteria, 56 Bacteria — Microprotein — Micrococci — Bacilli — Spirilla— Spores — Sapro- phytes— Parasites— Aerobes — Anaerobes — Coloration— Cultivation — Inocu- lation — Ptomaines— Toxines— Phagocytes — Antitoxiues— Protozoa — Rhi- zopods — Sporozoa— Infusoria — Plasmodium malarias. CHAPTER IV. Infectious Diseases, 68 Diseases caused by Micrococci, Bacilli, Spirilla : Septicaemia — Pyaemia — Septico-pyaemia. Staphylococcus pyogenes aureus, albus, citreus, Micro- coccus pyogenes tenuis, Staphylococcus pyogenes : Erysipelas — An- thrax — Foot and Mouth Disease — Glanders— Hydrophobia — Tetanus — Pertussis— Influenza — Hay Fever— Pneumonia — Tuberculosis — Lepra — Sy- philis —Chancroid — Gonorrhoea. Vlll TABLE OF CONTENTS. CHAPTER V. Infectious Diseases — Continued, 186 Mumps — Measles — Rubella — Scarlatina —Variola, Varioloid, Vaccination — Varicella— Diphtheria— Croup— Quinsy — Typhus, Relapsing, Typhoid Fever — Malaria — Yellow Fever — Cerebro-spinal Meningitis — Rheumatism — Dysentery — Asiatic Cholera— Cholera Morbus. PART II. DISEASES OF OKGANS. DISEASES OF THE ORGANS OF DIGESTION. CHAPTER I. Diseases of the Mouth, Fauces, and Pharynx, 349 Syphilis — Stomatitis, catarrhalis, ulcerosa — Aphtha — Noma— Glossitis — Angina — Tonsillitis— Globus hystericus — Cancer of the (Esophagus — An- gina Ludovici — Retropharyngeal Abscess. CHAPTER II. Diseases of the Stomach, . . . 363 Gastric Catarrh — Ulcer — Cancer — Gastrectasia— Gastralgia — Diagnosis, Diet, Treatment. CHAPTER III. Diseases of the Intestine, 397 Intestinal Catarrh — Ulcer— Haemorrhage of the Bowels— Typhlitis, Peri- typhlitis, Paratyphlitis, Appendicitis— Occlusion — Cancer— Peritonitis. CHAPTER IV. Diseases of the Liver, . 439 Icterus — Cholelithiasis — Abscess— Cirrhosis — Hypertrophic Cirrhosis- Simple Atrophy — Acute Yellow Atrophy — Weil's Disease— Hyperemia — Fatty Liver — Amyloid Liver— Cancer. DISEASES OF THE ORGANS OF RESPIRATION. CHAPTER V. Diseases of the Nose and Thr6at, . 478 Acute and Chronic Catarrh— Syphilitic Catarrh — Neoplasms. Diseases of the Larynx, . . .481 Catarrhal Laryngitis— (Edema of the Glottis— Perichondritis— Tuberculo- sis— Syphilis — Paralysis of the Larynx — Tumors. TABLE OF CONTENTS. IX CHAPTER VI. Diseases of the Lungs 489 Bronchitis, Acute, Capillary, Chronic— Bronchorrkcea— Putrid Bronchi- tis— Fibrinous Bronchitis— Bronchiectasis— Asthma— Emphysema— Pneu- monia, Catarrhal, Hypostatic — (Edeina of the Lungs — Atelectasis — Drowning — Embolism, Hemorrhagic Infarction — Abscess— Gangrene — Syphilis — Cancer, Sarcoma, Echinococcus—Pneumonoconiosis— Pleu- risy — Empyema — Pneumothorax — Hydrothorax — Hematothorax — Peri- pleuritic Abscess — Subphrenic Abscess. DISEASES OF THE ORGANS OF CIRCULATION. CHAPTER VII. Diseases op the Heart, 554 Pericarditis — Tuberculosis, Syphilis of the Pericardium— Hydroperi- cardium — Endocarditis — Sclerotic Endocarditis — Myocarditis — Heart Failure — Tuberculosis — Syphilis — Neoplasms— Neuroses — Palpitation — Angina Pectoris — Exophthalmic Goitre— Myxcedema. Diseases of the Blood Vessels, 590 Arterio-sclerosis — Aneurism of the Aorta — Phlebitis, # CHAPTER VIII. Diseases of the Blood, 597 Plethora — Hydremia — Lipemia — Uraemia — Choleinia — Blood Parasites — Anemia — Pernicious Anemia — Chlorosis — Leukemia — Pseudo-leukemia — The Hemorrhagic Diathesis — Hemoglobinemia — Purpura — Haemophi- lia — Scorbutus — Morbus Addisonii— Gout — Arthritis Deformans — Rachitis — Osteomalacia — Obesity. DISEASES OF THE GENITO-URINARY SYSTEM. CHAPTER IX. Diseases of the Kidney, . . 637 History — Albuminuria — Casts— Dropsy— Uremia — Hypertrophy of the Heart — Hyperemia — Anemia — Acute Parenchymatous Nephritis — Chronic Parenchymatous Nephritis — Renal Cirrhosis — Amyloid Degenera- tion — Tuberculosis — Syphilis — Floating Kidney. CHAPTER X. Diseases of the Pelvis of the Kidney, Bladder, etc., .... 663 Nephrolithiasis— Pyelitis— Hydronephrosis— Cystitis— Enuresis— Sperma- torrhoea— Impotence — Diabetes Mellitus — Diabetes Insipidus. DISEASES OF THE NERVOUS SYSTEM. CHAPTER XI. Diseases of the Nerves and Membranes, 685 Neuralgia, Trigeminal, Occipital, Intercostal— Sciatica— Coccyodynia— Headache— Migraine— Gastralgia— Enteralgia— Neuralgia of the Sperm- atic Cord— Neuralgia of the Joints— Neuritis— Multiple Neuritis— Spasm— Myotony— Torticollis— Lumbago— Paralysis— Facial Paralysis— Meningitis —Pachymeningitis— Hypertrophic Cervical Pachymeningitis— Leptomenin- . gitis. X TABLE OF CONTENTS. CHAPTER XII. Diseases op the Spinal Cord, 707 Myelitis — Locomotor Ataxia — Hereditary Ataxia — Lateral Sclerosis — Pro- gressive Muscular Atrophy — Infantile Paralysis— Bulbar Paralysis — Acute Ascending Paralysis— Spinal Haemorrhage— Syringomyelia — Acromegaly — Morvan's Disease — Raynaud's Disease — Brown-Sequard's Paralysis — Progressive Dystrophy — Pseudo-hypertrophy — Juvenile Dystrophy— He- reditary Atrophy — Facial Atrophy — Tetany. CHAPTER XIII. x Diseases of the Brain, 736 Apoplexy — Epilepsy — Tumor — Abscess — Localization of Lesions — Hyste- ria — Hypochondriasis— Neurasthenia — Chorea — Paralysis Agitans — Multi- ple Sclerosis — Dementia Paralytica — Avocation Neuroses — Insolation — Congelation — Saturnism — Alcoholism — Delirium Tremens — Cocainism — Poisoning by Opium — Poisoning by Nicotine — Poisoning by Gases. Notes, 799 Index, S07 LIST OF ILLUSTRATIONS. FIG. PAGE Chromo lithograph of pathogenic micro-organisms, vi 1. Female Acarus scabiei, dorsal surface, 4 2. Acarus burrow, with ova, .5 3. Pediculus capitis, male, 6 4. Hair with agglutinated eggs and nits, 6 5. Pediculus pubis, 7 6. Pediculus vestimenti, 8 7. Acarus folliculorum, 8 8. Achorion Schonleinii from favus cup, 9 9. Favus scutulum, 10 10. Hair and root sheaths in favus, infiltrated with conidia and my celia, . .11 11. Epidermis scale in herpes tonsurans, showing more mycelia than conidia, . 12 12. Hair in herpes tonsurans, 13 13. Onychomycosis, 13 14. Microsporon furfur, 14 15. Pityriasis; mycelia and conidia 15 16. Mycoderma albicans, 15 17. Transverse section of flake of coat of tongue after death in typhoid state, covered with mycoderma, 16 18. Thrush fuigus, 17 19. Leptothrix buccalis, 18 20. Actinomyces, . . .19 21. Actinomyces of the tongue, 19 22. Taenia saginata, . . . . 24 23. Segments of taenia in motion, 25 24. Ova containing embryos of Taenia saginata, 25 25. Calf's heart with measles of Taenia saginata, 25 26. Cysticerci, . ' 25 27. Measles in pork, 27 28. Pork tapeworm, 27 29. Head and neck of Taenia saginata, .28 30. Head of Taenia solium within that of Taenia saginata, to show differences, . 28 31. Head and neck of Taenia lata, 29 32. Ova of fish tapeworm, 29 33. Segments of taenia, ' . .31 34. Taenia echinococcus, . . . 35 35. Extended echinococcus with hooklets . . .35 36. Echinococcus sacs in the liver of man, 35 37. Echinococcus membrane with hooks, ' . .35 38. Echinococcus multilocularis, 37 Xll LIST OF ILLUSTRATIONS. FIG. PAGE 39. Ascaris lumbricoides, 38 49. Round worm, 39 41. Oxyuris vermicularis, .42 42. Oxyuris vermicularis, 42 43. Whipworm, female and male, 44 44. l-'ggs of entozoa, 44 45. Anchylostomum duodenale, • . .45 46. 47. Mature trichinae, .."_'.. • 46 48. Young trichinae in muscle, 47 49. Trichina encapsulated in muscle, ......... 48 50. Calcified relics, . . .48 51. Young trichina liberated from capsule, . . . ..'.■'• - .48 52. Encapsulated trichina, 48 53. Trichina in muscle, ... . . . . .50 54. Guinea worm, . ..-.'•-. .52 55. Filaria sanguinis, ... .53 56. Filarise in blood vessels, 53 57. Elephantiasis cruris lymphangiectatica • .53 58. Liver fluke, 54 59. Distoma hsematobium with ova, 55 60. Bacilli stained to show vibratile cilia and fiagella, . r . . . .57 61. Streptococcus, . . ... 58 62. Spirochetes of relapsing fever, . . .. . . . . . .58 63. Sarcina?, 58 64. Yeast plant, 58 65. Bacillus pneumoniae with gelatinous envelope, .58 66. Bacilli tuberculosis, showing spores, . . . . . . . . 59 67. Bacillus Havaniensis, 62 68. Scale surface culture (serum) of tubercle bacillus, . .... .62 69. Nail stick culture (gelatin) of pneumococcus, 62 70. Trichomonas intestinalis, . . ., . , . . . .65 71. Naked amoeba? coli, . . ...... . . . . .65 72. Cercomonas intestinalis, . . . . . . ., ? . ..65 73. Plasmodium malariaa, , . . . . . .66 74. Coccidia from the human liver, .66 75. Scirrhus of the breast, , . . . . . . . ... .67 76. Pus from an acute abscess, . . . . . . . . . .69 77. Septic infection of pectoral muscle after a " post-mortem " wound of the hand,. .............. 69 78. Temperature in a fatal case of sepsis, >j. .70 79. Erysipelas cocci in the cutis, . . . . . ... . . 73 80. Streptococcus erysipelatis, . .. . . ... . . . 74 81. Temperature in severe facial erysipelas, . . . . . . . 77 82. Anthrax bacillus, with and without spores, from spleen, . . . .82 83. The anthrax bacillus in the blood, . . . . .:■'.. .85 84. The bacillus of glanders, . . , ,. .. ... . . ,91 85. Farcy buds in the skin, . . . . . . . . . .92 86. Tubercular glanders in the nose, . . . ,.-■ ... . . . 93 87. Discharging cicatrices in the nose,. . . . -. . . . .91 88. Bacillus of tetanus, . . , ....... . . .107 89. Pneumococcus of Friedlander ; oval cells with gelatinous envelope, . . 126 LIST OP ILLUSTRATIONS. Xlll FIG. PAGE 90. Pneumococcus of Friedlander ; stick culture in gelatin, .... 126 91. Diplococcus pneumoniae, 127 92. Diplococci from sputum, acute pneumonia, early stage, . . . . 128 93. Diplococcus of pneumonia in sputum, much more highly magnified, . 128 94. Temperature chart ; fibrinous pneumonia, adult, 129 95. Temperature chart ; fibrinous pneumonia in child, 129 96. Section of alveolus of lung in croupous pneumonia, filled with exudate consisting of fibrin, with desquamated epithelium and red and white blood corpuscles (Delafield and Prudden), . . . . . .131 97. Diplococcus of pneumonia in sputum, 135 98. Tubercle bacilli — sputum, 138 99. Tubercle bacilli with spores, in sputum . 139 100. Tubercle bacilli in sputum, 140 101. Tubercle bacilli in sputum, . . 140 102. Tubercle bacilli in sputum, 141 103. Colonies of tubercle bacillus in scales on surface of blood serum, six weeks old, . . . - 141 104. Hectic {i.e. , septic) fever in tuberculosis, . . . . . . 147 105. Phthisical thorax in a girl eighteen years old, 147 106. Tubercular ulcer of ileum, 148 107. Tubercular ulcers in the larynx and trachea, seen on vertical section, . 149 108. Shred of elastic tissue in sputum, 151 109. Elastic tissue with epithelium and bacteria, .151 110. Bacillus tuberculosis in urine, 164 111. Tuberculous caries (stiffness) of cervical vertebra?, 165 112. Tuberculous caries (gibbus) of dorsal vertebras, 165 113. Leontiasis leprosa, 168 114. Mutilating leprosy, 169 115. Lustgarten's bacillus of syphilis, 171 116,117,118. Teeth in hereditary syphilis, . . . . . . .171 119. Syphilitic roseola with malformation of teeth, 172 120. Syphilis of the larynx with great deformity, 173 121. Tubercular syphiloderm of face, . . . . . . . .174 122. Syphilitic necrosis of cranium, 175 123. Syphilitic endarteritis 176 124. Gonococcus, '. 180 125. Gonococcus in pus cells, . . . 180 126. Non-specific bacteria, streptococcus and staphylococcus, found in urine, . 183 127. Cystin plates, gonorrheal thread, spermatozoids, 184 128. Temperature in simple measles, 193 129. Contrast between the fever of scarlatina and that of measles, . . . 194 130. Mild scarlatina, . . .205 131. Protracted scarlatina, . . . . 205 132. Fatal scarlatina, . . ... .205 133. Pock of small-pox, . . . . . . . . . . .221 134. Temperature chart in variola, showing secondary fever, . . . . 222 135. Mortality from small-pox in Boston, 236 136. Deaths from small-pox in Berlin and Yienna, . . . . . . 237 137. Strokes and cross-strokes for vaccination, . . . . . . 239 138. Bone point for vaccine virus, . . 239 139. Bacillus diphtherias from blood serum, • . . . . .... 246 XIV LIST OF ILLUSTRATIONS. FIG. PAGE 140. Streptococcus and staphylococcus from exudate, . . . . 247 141. Temperature chart in adynamic petechial typhus fever, . . ' . . 262 142. Temperature chart in ordinary typhus, 263 143. Temperature chart in typhus fever, 263 144. Temperature chart in typhus fever, 264 145. Temperature chart in typhus fever, 264 146. Spirilla of relapsing fever in the blood - . . 267 147. Temperature chart, relapsing fever, . . 268 148. Typhoid bacillus. Pure culture, 269 149. Typhoid bacilli in the wall of the intestine, 210 450. Typhoid bacilli from section of spleen, 270 151. Typhoid bacilli in mucous membrane of small intestine (child), . . 270 152. Typical temperature curve in severe typhoid fever, 271 153a. Typhoid fever with recrudescence. Primary fever, .... 277 1535. Typhoid fever with relapse after twenty-four days' interval. Relapse, . 278 154. Typhoid fever with recrudescence, 278 155. Temperature curve in man after injection of blood from patient affected with malarial (quartan) fever, 288 156. Plasmodium malarice, 288 157. Quotidian fever, 291 158. Tertian fever, 291 159. Quartan fever, 291 160. Temperature chart, yellow fever; mild case, 296 161. Temperature chart, yellow fever; typical severe case, .... 297 162. Temperature chart, yellow fever; protracted case, 298 163. Liver cells in yellow fever with necrotic masses in and between the liver cells, 299 164. Streptococcus from vomit (not black) of yellow fever. .... 299 165. Extreme opisthotonos, 303 166. Hyperpyrexia of acute rheumatism, 317 167. Torticollis, 322 168. Descending colon with sloughing pseudo-membrane. .... 327 169. Descending colon with oval ulcers, 329 170. Cicatrices of diphtheritic ulcers in the colon, 334 171. Comma bacillus of cholera, pure culture 337 172. Mould fungi, etc. , from mouth, . . . 351 173. The tongue coated white,' moist. Section from case of granular kidney, . 355 174. The tongue denuded, red, and dry (raw beef tongue). Section from cafe of peritonitis, 355 175. Pharyngo- nasal catarrh. Physiognomy before removal of adenoid tissue, 357 176. Pharyngo-nasal catarrh. Physiognomy after removal of adenoid tissue, . 357 177. Action of the digestive juices, 366 178. r l he soft stomach tube with openings at the end and side, and with re- ceiving glass funnel, 367 179. Partially digested matter from the stomach, ...... 367 180. Irrigation of the stomach . 370 181. Discharge by siphonage, 370 182. Microscopic appearance of section of scirrhus carcinoma, . . . .381 183. Hasmin crystals obtained by Teichmann's test, .;.... 382 184. Protozoa in the fasces, 400 185. Fasces under the microscope, 400 LIST OF ILLUSTRATIONS. XV FIG. PAOE 186. Tubercular ulcer of ileum, 405 187. Typhlitis. Ulceration of the vermiform appendix, 419 18S. Distended ductus choledochus, 444 189. Dilated bile ducts with thickened walls under pressure from cancer of pan- creas, 444 190. Two large gall stones from the gall bladder articulated by smooth surfaces, 447 191. Faceted gall stones, natural size, 447 193. Section of compound gall stone with concentric laminae and with nucleus formed by a smaller gall stone, 448 193. Section of gall stone with concentric nucleus; concentric laminae only at one end, 448 194. Section of cholesterin stone after removal of cbolesterin, .... 449 195. Cirrhosis hepatis (hobnail liver), 463 196. Apparent enlargement of the liver, the result of tight lacing, . . . 472 197. Cancer of the liver, 477 198. Nasal mucus, 478 199. Adenoid tissue at vault of pharynx 479 200. Posterior nares in the rhinoscope, 479 2.01. Normal larynx and trachea to bifurcation of bronchi, . . . .482 202. (Edema of the glottis, 485 203. Advanced tuberculosis of the larynx, 486 204. Papilloma of the larynx, 486 205. Fibroid tumor of the larynx, 486 206. Cancer of the larynx, 486 207. Normal larynx. Position of cords in deep inspiration, .... 487 208. Normal larynx. Position of cords in phonation, 487 209. Paralysis of the arytenoid in phonation 487 210. Paralysis of both thyro-arytenoids in phonation, 487 211. Paralysis of the arytenoid and both thyro-arytenoids in phonation, . .487 212. Paralysis of left recurrent in respiration, 487 213. Paralysis of left recurrent in phonation, 487 214. Paralysis of right posterior crico-arytenoid in respiration, . . . 487 215. Paralysis of both posterior crico-arytenoids in respiration, . . .487 216. Paralysis of both recurrents— cadaver, 487 217. Koch's syringe, . . " 491 218. Fibrinous bronchitis, ..." 498 219. Casts of the bronchial tubes expectorated in fibrinous bronchitis, . . 498 220. Asthma crystals, 510 221. Curschmann's spirals in the sputum of asthma, 510 222. Spirals with crystals in sputum of asthma, 511 223. Emphysema pulmonum, • . .519 224. Cellular pneumonia, 523 225. (Edema pulmonum. Desquamated epithelium enclosing particles of coal, 528 226. Marshall Hall's method of artificial respiration, 532 227. Sylvester's method, .533 228. Sylvester's method, 533 229. Howard's method, . .534 230. Mould fungi from sputum of abscess of lungs, 536 231. Sputum from abscess of lungs, showing elastic tissue, fat crystals, phos- phates, epithelium, pigment matter, pus cells, and bacteria, . . . 537 XVI LIST OF ILLUSTRATIONS. FIG. PAGE 232. Micrococcus pneumoniae crouposae, showing capsule from exudate in pleural cavity of inoculated rabbit, 543 233. Limited expansion of chest on left side, 544 234. Tyrosin in needle-shaped crystals arranged in bundles- and stellate groups, ; 548 235. Cor villosum. Fibrinous pericarditis, 555 236. Pericardial effusion with displacement downward of the liver, . . . 560 237. Endocarditis at and about the aortic valves, with ulceration, perforation of valves, and thrombi, 565 238. Sphygmographic tracing of normal pulse curve, 570 ^239. Pulse curve of mitral regurgitation with perfect compensation, . . . 570 240. Mitral regurgitation with systolic murmur at the apex, .... 571 241. Mitral stenosis with diastolic — i.e., presystolic — bruit at the apex, . .571 242. Aortic regurgitation with diastolic bruit at second right interspace, . . 572 243. Aortic stenosis with systolic bruit at second right interspace, . . . 572 244. Pulse curve in mitral stenosis with broken compensation ; feeble ascent, feeble force, 573 245. Hypertrophy of the left ventricle from insufficiency and stenosis of the aortic valves, 574 246. Pulse curve in aortic regurgitation, 574 247. Pulse curve in aortic stenosis, . . 575 248. Topography of the heart. Mechanical relation of the heart and abdo- minal aorta to the stomach and contiguous viscera, .... 583 249. Exophthalmic goitre, 587 250. Exophthalmic goitre; enlarged thyroid and prominent eyes, . . . 588 251. Exophthalmic goitre. Defective descent of upper lid in looking down, . 588 252. Aneurism of femoral artery, . 593 253. Aneurisms of the hypogastric artery, 593 254. Aneurism of the aorta, 594 255. Section of aneurism filled with clot, surrounded by dense layers of con- nective (fibrous) tissue, 595 256. Obliteration of right femoral vein, showing remains of a thrombosis three years before death 596 257. Poikilocythsemia, 600 258. Pernicious anaemia, 605 259. The blood in leukaemia, showing the disproportion of the white and red corpuscles, . . . . 609 260. Hypertrophy of spleen in lienal lymphatic leukaemia, .... 610 261. Gouty fingers 620 262. Tophi in the joints and tendons, .621 263. Arthritis deformans. Section of cartilage of head of femur, . . . 626 264. Deformities of rickets, 630 265. Casts of the urinary tubules in nephritis, 645 266. Retinitis albuminurica with irregularly scattered white patches, . . 648 267. Epithelium in urine of nephritis, . 649 268. Chronic nephritis; epithelial and mixed casts, 650 269. Topography of the kidney from behind, in relation to thoracic and ab- dominal viscera, 661 270. Crystals of oxalate of lime, 664 271. Mulberry-shaped red blood corpuscles in urinary sediment in haematuria, . 665 272. Epithelial cells from mucous membrane of renal pelvis, .... 668 LIST OF ILLUSTRATIONS. XV 11 of the mucous membrane an columns of the cord. FIG. 273. Urinary sediment in acute pyelitis, 274. Stone causing hydronephrosis, 275. Cystitis with gangrene and separation of the muscular coat, 276. Multiple (alcoholic) neuritis, . 277. Spasm of the trapezius, 278. Facial paralysis, . 279. Facial paralysis, . 280. Beginning sclerotic patches, . 281. Knee jerk after tap on patellar tendon, 283. Tabes : perforating ulcer of the foot, 283. Scleroses on cross-section of the lateral 284. Posture of healthy child, 285. Posture of infantile paralysis, 286. Bulbar paralysis, . 287. Pseudo-hypertrophic paralysis ; big calves of legs 288. Pseudo-hypertrophic paralysis ; attempt to rise from floor, 289. Pseudo-hypertrophic paralysis ; patient "climbing up his thig 290. Forms of hemiplegia, 291. Epilepsy, 292. Tubercular tumor of middle lobe of cerebellum, 293. Gliomata of left hemisphere, .... 294. Cerebral localizations. Outside view, 295. Localizations in the cerebrum. Inside view (Dana), 296. Chorea magna, . . . . . 297. Hysterical contracture of right leg and foot, 298. Position of the hand in paralysis agitans, 299. Attitude and gait in paralysis agitans, 300. Duchenne's apparatus for relief of writer's cramp, d par hs. PAGE 668 670 671 691 692 694 695 712 714 715 717 724 7 -J 4 726 732 733 733 740 746 750 751 755 756 759 760 770 771 780 PART I. GENERAL DISEASES " . . . For it is also thus in nature, the greatest balsams do lie enveloped in the body of most powerful corrosives ; I say moreover, and I ground upon expe- rience, that jjoisons contain within them- selves their own antidote and that which preserves them from the venom of them- selves, without which they were not dele- terious to others only, but to themselves also." — Thomas Brown, M.D., Reh'gio Medici. IXFECTIOXS-PAEASITES. OHAPTEE I. Most of the diseases of plants are produced by parasites. This fact, like the discovery of the cell structure in histology, has finally been brought to bear upon the diseases of man (pathology) and other animals, with the discovery in most cases of the same cause. Thus, it has been ascertained that diseases come, for the most part, from without, and not from within. The parasites of man are both animal and vegetable. Larger parasites lodge upon the surface — Ectozoa ; or through the food or drink reach the interior of the body — Entozoa. The ectozoa produce many of the diseases of the skin : entozoa are worms in the intestinal canal. Most of the vegetable parasites are so minute as to be microscopic. They are known as microbes or micro-organisms. They reach the recesses of the body by way of the mucous membranes or by inocu- lation of the skin. They multiply in the interior of the body to pro- duce symptoms, both by their presence and their products (toxines), and cause the group of diseases distinguished as the infections. Pathogenic micro-organisms are known. 1, by their morphology — that is, their size, shape, and general appearance ; 2, by their chemical affinities, as shown in their reactions to coloring matter ; 3, by their preference of soil in cultivation experiments, and the manner in which they grow in the soil ; 4, by the effect produced by their intro- duction into the bodies of various animals. The mass of micro-organisms belongs to the vegetable kingdom, to the subdivision cryptogamia, which forms neither flowers nor .seed, but reproduces itself by spores. Pathogenic micro-organisms ma}' be divided into : 1. Fungi, or moulds. 2. Ferments, or yeast plants. 3. Bacteria, or schizomycetes. -±. Protozoa. The fungi include the various vegetable growths, often of such magnitude as to be visible to the naked eye, which cause many ECTOZOA — ANIMAL. skin diseases, and sometimes, by metastasis, as in the case of the actinomyces, affection of the internal organs. Yeast plants produce the various, chiefly the alcoholic, fermentations. Bacteria cause most infectious diseases. Protozoa certainly produce malaria and probably cause cancer. ECTOZOA. ANIMAL. Scabies (scurf; itch). — An eczema produced partly by the itch insect ( Acarus scabiei) itself, but chiefly by scratching in relief of the itch the insect causes. The disease has been always known, is alluded to in the Bible, and was formerly regarded as a constitutional (blood) malady, the cure of which might entail worse evils. The Acarus scabiei has a hard, crab-like body with thorny exterior; stiff hairs protrude from its borders. The head has strong jaws, which work like scissors and are fixed with teeth. Respiration is wholly cutaneous. The animal is bisexual. The female is oval- shaped, broader than long, 0.35x0.23 mm., white or gray ; the male smaller, 0.25 X 0.15 mm., brown or yel- low. Each has two pairs of extremities in front and behind, the first pair provided with suckers, a hinder pair in the male with fasteners. The male lives in slight excavations which he makes in the surface of the skin; the female bores for herself lightly curved burrows or canals, three centimetres long, in the course of which, as she advances, she deposits eggs, one or two per day. The young acari shed the skin three or four times at intervals of six days ; first in fourteen to seventeen days, to appear after the first moult with eight legs — hav- ing had but six hitherto — and after the third with mature sexual organs. The insect seeks naturally regions where the epidermis is thin and the deeper layers succulent, as the front of the wrist, sides of the fingers, space between the fingers, front of the axilla, flexure of the elbow, penis, nipple, etc. The face is spared except in bad cases, and in sucklings who may be infected by nurses. So, too, the dis- ease may be carried, by scratching, to unwonted seats, even to the hairy scalp. Fig. 1.— Female Acarus scabiei dorsal surface. ECTOZOA — ANIMAL. Scratching develops eczema, which is sometimes obstinate and extensive, and may require treatment after destruction of the cause of the disease. The lesion is that form of superficial irritation which shows itself in itch ing, and which may vary in every degree of intensity from annoyance to torture, according to the extent of the disease and sen- sitiveness of the individual. It is usually tcorse at night and may exhaust the strength through insomnia. The diagnosis rests upon, 1, the itch — the situation of the lesion; 2, the character and course of the canals — curved lines colored with freces and studded with salient points ineffaceable on washing ; 3, the demonstration of the insect itself — a white granule at the end of a canal, which, with a little practice, may be lifted out under a lens on the point of a knife or a pin. ■~ :r J ::'i .'fey A ■ ■■» ^*s^ mm) Fig. 2.— Acarus burrow, with ova. Treatment calls for the destruction of the parasite and all its progeny — usually an easy task — and in aggravated cases applica- tions in relief of the eczema. There is much choice of remedy; as a rule, mild means are the best. One of the following ointments should be thoroughly rubbed into the skin : 1 J} Balsam i Peruviani, Styracis liquids aa 5 i. M. 2 ty Florum sulphuris, Olei rusci , .aa 3 ij. Cretae preparatae gr. xv. Saponis viridis, Axungise , , aa \ ii. M. 3? ^ naphthol z ss. Saponis viridis = iss. Cretae preparatae 3 ij. Axungise |nij. ECTOZOA — ANIMAL. 4. A more elegant but more expensive preparation : $ Lactis sulphuris 1 ij. Potassii carbonatis 3 vi. Olei lavandulce, Olei caryophylli aa gtt. x. Axungise q. s. Ft. unguentum. Recipes No. 2 and 3 are better than No. 1. No. 3 is the best, be- cause it irritates less and soils least. In all cases a good quantity must be thoroughly rubbed into the affected parts. Woollen cloth- ing should be worn, that the surface be not robbed by absorption. If there is still itching the inunction must be repeated on the following day. Bath after several days. The cure of the scabies is now com- plete. Any eczema left will disappear under diachylon ointment. Bathing, as it aggravates eczema, should be avoided for four or five days, or until the skin under the ointments dries and desquamates. Finally, after bathing, the skin may be anointed with vaseline or cocoa butter. Pediculus Capitis (head louse). — An elongated, hard body, 2 x 1 mm. , which cracks between the fin- ger nails, with six feet provided with claws for climb- ing and clutching hairs. The female, which greatly — Pediculus outnumbers the male, glues her eggs to hairs by a layer of chitin, commencing at the head end of the hair and depositing eggs upward, as many as fifty in successive layers, so that the duration of infection may be determined, on inspection with a lens, by the situation of the eggs or young (nits). The young escape in three to eight days, and become mature in eighteen to twenty days. A single female may give birth within six weeks to five thousand young. The irritation caused by pediculi causes eczema through scratching ; and sts such regions are avoided in combing the head, they offer quiet retreat for multi- plication of the parasite and aggravation of the eczema. Continued neglect may thus lead to suppuration and agglutination of the hair into a foul, offensive mass or cap, the plica polonica. The insect is strictly confined to the hair of the head, but the resultant eczema may extend to the neck or face, or in bad cases lead to lymphangitis and swell- ing of the neighboring glands. capitis, male. Fig. -Hair with Cases of light infection are best treated by frequent agglutinated eggs. and nits. use of the fine-tooth comb and thorough ablution with soap. More extensive infection calls for a parasiticide, as a mixture ECTOZOA — ANIMAL. ( of equal parts of petroleum and balsam of Peru, which may be most thoroughly applied after cutting the hair short. The worst cases require more thorough saturation, as by the application and wear- ing, after inunction, of a flannel cap soaked in the same mixture made thinner by the addition of one-fourth part olive or cod-liver oil. Any fixed or volatile oil kills all kinds of lice (Leidy). The eggs and nits are afterward dislodged with saturated solutions of soda. Crusts are best softened with cod-liver oil. The eczema dis- appears with destruction of its cause. Pediculus Pubis (morpio; crab louse) finds its habitat on any hairy surface except the head, but is especially at home at the pubes, whence it is derived in sexual congress, and where it may be seen on close inspection as a small brown speck near the skin. It has the same general construc- tion as the Pediculus capitis, and the eggs are fastened to the hair, only close to the root, by the same chitin. The insect is effectually destroyed by mercury, best in the form of the white precipitate ointment. Two applica- tions of the size of the end of the little finger will always suffice to relieve the itching, ec- zema, or other effect, with the eradication of FlG " 5 - Pediculus P* bis - the cause. When mercury itself produces eczema or is contra-indi- cated from any cause, it may be substituted by naphthol with olive oil 1 : 10, or creolin 1 : 50. The remedy should be applied with cotton at night, and the application should be repeated on the following night, whereupon on the next morning it may be washed off with soap. To destroj T the young of subsequent growth, the application should be repeated at the end of one and two weeks. The most potent preparation for permanent cure — i.e., to destroy nits and eggs — is (Saalfeld) : Y P Hydrargyri bickloridi gr. x. Aceti communis § viii. M. S. Apply morning and evening for three days. Pediculus Vestimenti (body louse; clothes louse). — The largest of all the lice, 3-5 X 1-2 mm. It has the same general construction as the species above described, but lives in the clothes, and leaves the folds and creases, in which it lies secreted, to suck blood from the body as food. The irritation thus produced is intensely aggravated by scratching, so that the skin is torn by the nails and the surface is literally lacerated in every direction. Urticaria, excoriations, ec- zemata, pustules, furuncles, and actual ulcers may form in these regions. Parts of the body which suffer most are surfaces of closest ECTOZOA — ANIMAL. Fig. 6.— Pediculus vestimenti. contact with the clothes, as at the back of the neck and shoulders, sacrum, nates, hips, etc. • or regions of friction, as at the ivaist, wrist, line of the garter, etc. Continued irritation at these places leads to deposit of pigment, so that the affected sur- face may be deeply discolored. Infection is most ex- tensive in the class of peripatetic pilgrims commonly known as tramps, but is not infrequently seen in the higher classes as accidentally contracted in hotels, sleeping cars, ship cabins, etc. Moreover, exterior and interior do not always correspond. Undercloth- ing may be worn so long as to become a good breed- ing place after the slightest infection ; the clothing may be clean and the bed foul, etc. Treatment, to be effective, must be radical. The clothes, bedding, etc. , must be burned, boiled, steamed, or subjected to dry heat at 212° F. for twenty-four to forty-eight hours, or, when this is not practicable, saturated for hours in a solu- tion of sublimate 1 : 1000, or in crude petroleum. The surface irri- tation disappears with destruction of the cause. Acarus Folliculorum, an elongated, 0.08x0.02 mm., worm- like body, with mandibles and four pairs of extremities on the upper third of the body, is found in the secretion of the oil and hair glands, especially of the nose, temples, cheeks, external ear, etc., and rendered visible under the lens after expression of the contents of the gland by the fin- ger nails. These contents, of cheesy consistence, often with a top of black coal dust, flattened out under an object glass are seen to iD elude, for the most part none at all, but at times one, or exceptionally more — in re- corded cases as many as twenty — acari. The animal always lies head downward, and seems to be perfectly innocuous to man, though allied species do damage to the skin in lower animals. Pulex (the common flea) in its bite produces petechise with hypersemic areola, which fades on pres- sure and soon disappears altogether, while the petechise persist for several days. The flea bites usually covered fomiuiorum' surfaces in light contact with the clothes, as the back, chest, thighs, etc. Confusion with petechial eruption is avoided by observance of the region affected — the legs in purpura, the lower abdomen in variola, the upper abdomen in typhoid fever, etc. The central blood point of the fresh flea bite, and the dark -brown or black specks which mark the deposit of fseces, suffice for diagnosis. Pulex penetrans (the sand flea) is found along the coast Fig. 7.— Acarus ECTOZOA — VEGETABLE. 9 regions. The female penetrates the surface to suck blood and leave, in the course of three or four days, more severe inflammation of the skin. Erysipelas, lymphangitis, ulceration, gangrene, even tetanus, have been thus introduced. Cimex lectularius (the bedbug) makes distinctions, in that it selects certain individuals and spares others. It produces in sen- sitive subjects, especially infants, itching urticaria, eczema, and, in consequence of scratching, more or less extensive incrustation. The insect makes its excursions in search of food at night only, and attacks more especially exposed surfaces — face, neck, and arms. These points suffice for diagnosis. Mosquitoes, Wasps, Bees, Horxets, or other Flies, and other insects, may produce lesions of the skin by bites, by the de- posit of eggs (maggots) in wounds, and, in the case of wasps and bees, by the insertion of poisonous matter. The history makes the diagnosis. The writer once failed to get a diagnosis from a class of students in the case of a patient semi-comatose with typhoid fever, one-half of whose face was thickly studded with papules while the other half was wholly free, the studded half having become exposed in the night from under the mosquito bar. The application of dilute liquor animonise 1 : 10, alcohol, or water with the addition of a few drops of carbolic acid or of creolin (one or two per cent), allays the irritation and neutralizes the poison of the bite. the VEGETABLE — DERMATOMYCOSES. Favus (honeycomb) ; tinea favosa. — An affection, chiefly of hairy scalp, produced by the growth of a mould fungus named by Remak in honor of Schonlein, its discoverer (1839), the Achorion Schonleinh. The disease begins as a papule penetrated by a hair. The papules grow gradually to the size of a ten-cent piece, flattening and sinking in the centre to form the characteristic saucer-shaped masses, scales, or cusps of sulphur-yellow color, the so-called scutula (dish). Crushed between the fingers the scales crumble, to emit a peculiar musty odor. Particles placed under the micro- scope show, with epidermis scales, hair frag- ments, detritus, etc., a wilderness of threads (mycelia) and spores (conidia), the cause of the disease. In the course of time the favus crusts co- alesce to form a more uniform mass : the invaded hairs lose their Fig 8.— Achorion Schon- leinii from favus cup (Ka- posi). 10 ECTOZOA — VEGETABLE. lustre, appear as if powdered, become fragile, and are easily broken off or detached ; in bad cases, where the papilla is attacked, they may be permanently destroyed. The surface, which is now con- verted into a mortar-like, dirty yellow mass (honeycomb), presents an appearance offensive to both sight and smell. Crusts, which were before so adherent as to be detached with hemorrhage, now des- quamate continuously and the color gradually changes to gray or brown. The disease may in exceptional cases attack uncovered surfaces, and in still rarer cases invade the nails (onychomycosis favosa), which then show the same sulphur-yellow deposits with degeneration and detachment of nail substance. The characteristic elements of the- Fig. 9. — Favus scutulum : a, free border ; 6, corneal layer ; c, d, mycelia ; e, conidia; /, epithe- lium: y, papilla; h, cell infiltrate at base of scutulum; i, cutis (Neumann). growth have been observed once (Kundrat, Kaposi) in matter voided from the stomach. The disease is common to many domestic animals, especially to mice, rats, and cats, from the last of which it may be contracted, though infection usually comes from an affected bedfellow or from use of the same comb. It is not eminently contagious and may re- main confined to one child in a family in close contact with others for years. The diagnosis rests upon the form of the favus crusts, the yel- loiv color, the odor like that of mice, the destruction of the hair; more positively upon the presence of the parasite, which is best dis- played by the addition of a few drops of liquor potassse and examina- tion with glycerin. The diagnosis has been made easy since the dis- covery byNeisser that a favus crust touched ivith alcohol is stained. ECTOZOA — VEGETABLE. 11 a deep yellow, a change which does not occur in crusts of eczema'or other simulating affections. Treatment.— -The crusts must be softened with oils, that a parasi- ticide may be brought to bear directly upon the cause ofjthe disease. Fjg. 10 —Hair and root sheaths in favus, infiltrated with coaidia and mycelia. In uncovered places saturation with cod-liver oil over night, and the subsequent application of carbolic acid, naphthol, resorcin, thymol, or sublimate, according to the following formula?, suffice to control the disease. The disease is much more obstinate on hairy surfaces/ and successful treatment demands epilation. After softening bv 12 ECTOZOA— VEGETABLE. saturation over night with cod-liver oil under a flannel cap, the head should be thoroughly washed with soap liniment, dried, and all loose hairs extracted. Thereupon one of the following preparations must be rubbed into the scalp with a stiff brush, whereby it is not neces- sary to give pain : 1 R Acidi carbolici 3 ss. Olei olivse . I iv. M. 2 R Resorciu 3 i. Unguenti petrolati ^iv. M. 3 R Thymol 3 i. Chloroform § ij. Olei olivre | iv. M. 4 R Unguenti hydrargyri ammoniati 3 ij. Unguenti petrolati § ij. M. .._; ' - - r - — . ..— -^ ,'■. ■' ■ - Fig. 11.— Epidermis scale in herpes tonsurans, showing more mycelia than conidia (Kaposi). The most powerful parasiticides, when well borne, are pyrogal- lic acid ten per cent, or chrysarobin ten per cent, or alcoholic subli- mate solution 1 : 100. Herpes tonsurans (kpnt}?, creeping eruption; tondeo, to shear); herpes circinatus ; ringworm. — A disease of both hairy and free surfaces, caused by the growth on and in the skin of the trichophyton (hair-like) tonsurans — long, narrow threads which divide but little, form no masses, but much more readily invade the hair. The parasite is common to domestic animals, dogs, cats, cattle, between which and man the disease is transferable. It may be cul- tivated in beef infusions, on agar, potato, etc. ECTOZOA — VEGETABLE. 13 On the scalp it attacks and bends or breaks off the hairs, to leave partly bared, as if badly cut, or later bald, spots, smooth, scaly, or cov- ered with pustules or crusts with more or less reddened edge. The hairs look dull and dusty, and the skin of the scalp is lightly infil- trated with serum and is slightly sensitive to pressure. On a free surface the disease appears in small vesicles upon a - f h ; \, >: reddened base. The vesicles nip- '. r ; ! -L. > '"■-_■' ;■;; :\ ture, to leave the red points cov- ' l - :'i ered with small scales. In the : progress of the disease new ve- ; - , ; V x y. 1 sides develop in the form of a ring about the first set, while the original centre fades to leave ■ " "%, no trace. The process repeats ? ; " i] itself in this way with an ad- ;<|fe vancing circular or serpentine -> : wall of vesicles, or contiguous '/>"■ / -, rings break into each other to ^^ i'i' i 'i i V.i -■ ^ kfi '''''te i- f aggravate the inflammation and fig i5.-Hair in herpes tonsurans, show pustules, crusts, or more extensive eczema. Desquamation finally sheds the parasite, and the disease ceases spontaneously in six weeks to six months, A good illustration of this process is often seen on delicate surfaces ;>v'"V Fig. 13.— Onychomycosis. kept warm and moist by apposition, as where the skin of the scrotum rests upon the inner face of the thigh. Maceration with abrasion of the epidermis forms here a good nidus for the parasite, which ad- vances with an outlying marginal ring of papules to constitute the affection known as eczema marginatum. The finer forms of myce- 14 ECTOZOA — VEGETABLE. lia sometimes found in this affection have received the name mi- crosporon minutissimum. The nails invaded by the parasite (onychomycosis tonsurans) be- come opaque, scaly, and brittle. More extensive inflammation results at times from invasion of the hairs of the beard, with the formation of papules and pustules, which may coalesce to form ulcers with wide infiltration of the skin, constituting the condition known as the parasitic sycosis menti. The disease is contracted in barber shops. The common acne men- tagra is also parasitic, but is produced by the Staphylococcus au- reus. Treatment. — During the stage of vesiculation or abrasion on a free surface, no other treatment is necessary than the use of some inert powder, as of starch, to prevent contact with air or with op- posed surfaces. Later stages call for : 1 R /?-naphthol ... 3 ss. Saponis viridis = 3 ii. M. 2 R Acidi pyrogallici 3 i. Unguenti petrolati 3 x. M. 3 R Hydrargyri chloridi corrosivi, Aquae destillatae, 1:1000. M. 8.: Wash the surface three times a day. On the hairy scalp successful treatment requires, in addition to softening of crusts with olive, almond, or cod-liver oil, removal of dead or diseased hairs, with subsequent destruction of the fungus by one of the parasiticides mentioned. Penn applies sublimate with elec- tricity. The sponge of the positive pole is dipped into a three- to five- per-cent sublimate solution and applied to the affected region ten minutes with a current not too strong-. Pityriasis versicolor is that discoloration of the sur- face, pretty uniformly yellow or brown, not so variegated as the name implies, which results from the deposit and growth of the microsporon furfur, a vege- table parasite distinguished only from those hitherto described by its smaller size and more superficial growth. It develops by prefe- rence upon warm, moist surfaces of the trunk, neck, flexures of the Fig 14. —Microsporon furfur: a threads; b, conidia; c, epithelium. mycelium ECTOZOA — VEGETABLE. 15 joints, etc., and is most commonly seen on the skin over the pit of the stomach, especially in the uncleanly or phthisical, patients who sweat much. The discolorations vary in size from minute spots to tracts which may by spread or coalescence cover large regions of the body. Treatment. — Friction with carbolic acid, sulphur, or naphthol soaps usually suffices to reach this parasite. The following is an eli- gible preparation : B /S-naphthol gr. x. 8piritus lavandulse 3 i. Saponis viridis 3 i. M. Other forms of pityriasis — viz., rosacea, maeulata. circinata — and various dermatomycoses — erythrasma. etc. — are produced by allied hyphomycetes. Carter considers the Madura disease, in which tumors Fig. 15.— Pityriasis ; mycelia and conidia. Fig. 16.— Mycoderraa albicans. and ulcers form on the hands and feet, the so-called fungus disease of India, as a mycetoma. Certain diseases of invertebrate anim Is are found to be due to fungi. The silkworm is destroyed by the muscardine, Botrytis Bassiana ; the crab by penetration of its flesh by the Achyla prolifera; and the common house fly is killed by pene- tration of the mycelia of a species of empusa. A^transition from the external to the internal parasites is offered in thrush and actinomycosis — affections of the mucous membrane and deeper structures of the mouth. Thbush (thrush ; curd; German, Soor; French, miiguet). — A su perflcial disease of the mucous membrane, mostly of the mouth, caused by the deposit and development of the thrush fungus (XEyeoderma albicans), and characterized by the formation of white spots and sur- faces non-adherent or but loosely adherent to the epithelial layer, clinically by sore mouth and dysphagia. The thrush fungus was formerly regarded as the Oidium albicans, but since it has been observed to grow by the budding process it is 16 ECTOZOA — VEGETABLE. classed among the ferment fungi and called the My coderma albicans. It is readily recognized by its mycelia and conidia, and may be cul- tivated on various soils. It has a wide distribution in nature, but not much affinity for the soils offered in the body of man, as it develops on the mucous membranes only of the weak and debilitated or in persons of unclean habits. It is found in the mouths of sucklings, especially in cases of gastrointestinal catarrh or in cases of use of unclean utensils for food, espe- cially unclean nursing bottles and nipples. It is seen also upon the breast nipples of nursing women careless as to cleanliness ; and these two sources, the natural and artificial nipple, introduce the disease to the mouth of the child. Typical cases are also encoun- tered in the adult where the body has become debilitated by long- standing disease, typhoid fever, tuberculosis, diabetes, or any ma- rasmus. In the last stages of tu- berculosis the whole interior of the mouth and pharynx, as far as may be seen, may be lined with thrush. The fungus is also found upon other mucosae — larynx, oesopha- gus, stomach, vagina, glans penis, and rectum. It lies at first under and in the epidermic layer of the mucosa, but is speedily exposed by desquamation and is found mingled with epidermic scales, detritus, and the myriad bacteria of the mouth. Occasionally, as a great exception, it is carried by metastasis to distant organs. Thus Schmorl found it in the kidney, and Zenker (sole observation) in mul- tiple abscesses in the brain. Such transfer is exceedingly rare, but the possibility of it has been proven in animals by Klemperer, who produced a general mycosis by injection of it into the blood of the rabbit. Aspirated into the lungs of man, it helps to produce the catarrhal (Schluck) pneumonia of paralyzed, reduced, debilitated (senile) patients. - ; '.^- >k Fig. 17.— Transverse section of flake of coat of tongue after death in typhoid state, covered with my coderma (Dickinson). ECTOZOA — VEGETABLE. 17 Symptoms. — Thrush may be latent. In fact, most cases of light deposit hitherto unsuspected are recognized only by inspection — as of the process of dentition, for sore throat, etc. The disease shows itself at first as small pinhead deposits of white cheesy matter, bor- dered with a red ring, upon the surface. The points coalesce to form large surfaces, which may coat extensive areas or absolutely line the whole cavhy. The deposits may be detached without much break of surf ace — i. e. , without haemorrhage — to leave a lightly reddened, hard, slightly abraded base, which is tender to the touch. The secretions of the mouth are always acid, not, however, in a necessary relation to growth of the fungus, as Kehrer showed that it will thrive in solu- tions of the lactate of soda and potash. Fig. 18.— Thrush fungus : a, mycelia with polar granules; b, conidia; c, epithelium; d, leucocytes. When present in any quantity it causes soreness of the mouth, with consequent aversion to food and at times even difficulty of deg- lutition. Diagnosis. — The disease is usually recognized at a glance, even though the color may be changed, by admixture with food or foreign matter, to a dirty gray or brown. The deposit is confined to the surface of the tongue, cheeks, lips, or only later involves the throat, and then without the adenopathies which distinguish sore throat from other causes. In case of doubt the microscope reveals the true character of the deposit. The specimen, best examined in glycerin, shows leucocytes, detritus, conidia (spores), and threads with clear contents, each section of which contains two polar granules. Treatment. — Prophylaxis is a main element. The disease may be avoided by care of the mouth and scrupulous attention to utensils, nursing bottles, nipples, etc., which should be boiled, steamed, and washed in soda. In fact, bottles and nipples should be dispensed 18 ECTOZOA— VEGETABLE. with as soon as possible. All expenditures of patience in feeding with the spoon and from a glass (not a cup, even though of silver or gold) will be thus amply rewarded. The oral cavity of patients with prostrating maladies (the tuberculous, etc.) must be cared for every day. The child^s mouth may be best washed out with clean linen rags dipped in five- to ten-per-cent solutions of soda or borax. Deposits of thrush may be thus mechanically washed away, and the parasite itself dislodged and destroyed. The base may be touched with nitrate of silver (two-per-cent) or with — R Potassii permanganatis gr. v. Aquas destillatae § i. M. Apply with cameFs-hair brush. A very mild, safe, and efficacious remedy is methylene blue, two- or three-per-cent solution, applied with a brush. Syrups, because they favor the development of fungi, should be always avoided in the preparation of any remedy for thrush. The general health must be fortified by the tincture of iron,' malt, cod-liver oil, fresh food, and open-air exercise. The Leptothrix buccalis is the common fungus which abun- dantly infests the mouth. It is found on the coat of the tongue ; on the teeth, to the caries of which it is said to contribute; and in the crypts, cheesy contents, of the ton- sils, where it produces a form of tonsillitis which simulates in its deposits and symp- toms a beginning diphtheria. The lepto- thrix may be always recognized by its fig. 19. -Leptothrix buccalis. mycelia. Under the iodine-potassium-io- From tartar of teeth. dide solution it takes on a purple color. Actinomycosis {anrk, axTivos, ray, /xvx?/,, fungus) ; big jaw, swelled head, bone tumor ; German, Kinnbeule, Holzzunge, Knoch- enkrebs. — A peculiar infection of cattle as well as man, caused by the ray fungus, actinomyces, characterized by development of the fungus in mass, with excessive overgrowth of the soil in which it grows, at- tended by metastases to different organs, marked by symptoms of pyaemia and marasmus, and distinguished always by the detection of particles of the fungus itself in the mass, in its metastases, and in its discharges. History. — Bollinger (1877) first saw the fungus as the cause of the disease known as the big jaw in cattle. Israel, of Berlin, saw the parasite in man in the same year of its discovery in cattle, and de- scribed it as a new mycosis of man. Ponfick (1879) established the identity of the disease it caused in man with the actinomycosis of cattle. Belfield, of Chicago, first recognized the parasite in cattle in ACTINOMYCOSIS. 19 our own country as the cause of the disease known as swelled head, -technically as a jaw sarcoma. Pathology.— Actinomyces constitutes a mass so large as to be visible to the naked eye. It consists of a conglomeration of innu- merable threads of mycelia about a central mass of the same struc- ture, from which the threads radiate in every direction to construct the ray shape. The mycelia can be always recognized by their clubbed extremities, and the mass, on an average about one-fortieth of an inch, is as large at times as one-tenth of an inch in diameter. Agglomerated masses may be as big as a fist. Fragments detached and discharged have a tallowy consistence and a distinctly greasy feel. Peripheral protrusions divide dichotomously, and show, as stated, distinctly clubbed- or pear-shaped extremities, to resemble in certain fragments the appearance of a hand or glove with out- stretched fingers. The peripheral radiation from a central mass gives, under the microscope, something of the appearance of an aster Fig. 20. Fig. 20.— Actinomyces. Fig. 21.— Actinomycosis of the tongue: a, actiDomyces mass; b, cell masses; c, pus corpuscles: pass from the rectum in fourteen days after ingestion of the ova ; and as each female may give issue to successive crops, though the dura- tion of individual life is short, the progeny is maintained often throughout the life of the host. The eggs, t1 l_ X ygVo mcn m diameter, are oval and plano-convex. The embryo develops rapidly, in from four to six hours, so that the whole process may be easily followed up with the microscope. The myriad ova and rapid de- velopment render self-infection almost unavoid- able. In fact, ova are always to be found in- sinuated (by scratching) under the ringer nails of infected individuals. Helminthologists be- come infected in handling the worms. Threadworms, though active in movement, have little power of migration over a dry sur- - face, perishing rapidly after leaving the bowel ; hence infection from contact, as from a bedfellow who happens to be the host of worms, cannot occur. The introduction of ripe ova from an infected indi- vidual into the stomach is an essential factor in etio- logy. Infected mothers, nurses, cooks, waiters, etc., generally convey the ova. Biting the nails is a not uncommon mode of reinfection. Orphan and in- sane asylums furnish all the prerequisites for rapid dissemination. Symptoms. — So long as the parasite remains above the rectum it gives rise to no symptoms. De- scent of the mature female into the rectum to dis- charge its ova and escape at the anus — which occurs most frequently at night, on account of the quiet of the body at night and the greater warmth of the bed— is attended with itching, bor- ing, burning sensations, which may become so intolerable as to prevent sleep and lead thereby to nervous distress. Migration into • the vagina extends the surface of irritation, and may induce pruri- tus, masturbation, and nymphomania. It is questionable if the-- Female with ova. Oxyuris vermi- Fig. 42. — Oxyuris vermicularis, natural size; one female, two males. ENTOZOA. 43 worm ever finds its way beneath the prepuce or into the male urethra, though it may be carried thither by the fingers. The in- tense irritation about the perineum, with manipulations for its relief, may of themselves excite the genital apparatus and thus lead to a train of nervous disorders. Diagnosis. — Direct inspection of the anus, more especially after the use of an enema, discloses oxyurides in numbers, so that a search for the ova is generally superfluous. The ova may, however, always be found, in the absence of visible worms, in scrapings of the upper parts of the anus, as everted in defecation, upon paper used in wip- mg, or in its uppermost parts accessible to the handle of a scalpel or the eye of a catheter. Vix declares that he never found a single case where the eggs were not visible in countless numbers in the first field of vision. The detection of the worm or its ova, it is need- less to state, affords the only positive diagnosis. Prophylaxis. — Scrupulous cleanliness on the part of those af- fected, regular ablutions before meals, and the frequent use of the nail brush, are preventive measures of importance. Children cannot be prevented from putting their own fingers in their mouths, but surely the filthy habit might be stopped of inserting those of their attendants. The bad habit of biting the nails can be broken up. After all, the only real prophylaxis is the speedy evacuation of every member of the colony in affected individuals. Treatment. — Though some degree of moisture is necessary to the growth and reproduction of the threadworm, it cannot live in water, which causes it to swell up and burst. Hence the administration of anthelmintics is unnecessary and, because of the distance of the worms from the mouth, inefficacious. Heller saw oxyurides creeping about ' ' quite lively " under strong solutions of carbolic acid applied as a dressing to condylomata of the perineum. Inundation and maceration with water, if practised effectively, suffice to destroy and remove them. Simple as it may seem to accomplish it, the treat- ment is nevertheless seldom successful. Failure is due to the fact that the applications are limited to the rectum. Irrigation with soap and water, because less irritant to the bowels than simple water, by means of a long rectal tube or catheter in the knee-elbow posture, best dislodges and discharges these worms. Irrigation with luke- warm water, two to four quarts, should precede the injection of the same quantity of soap water, and the operation should be repeated at intervals of one or two weeks, at least three times, that subsequent broods, previously secreted in the sacculi of the intestine or vermi- form appendix, may be successively attacked. Ammoniated mercu- rial ointment best relieves subsequent itching and irritation about the perineum. 44 ENTOZOA. Whipworm. — Trichocephalus dispar (6 pig, rpz^-o^ hair, xecpaX??, head; dispar, unequal), male one and a quarter, female two inches in length ; is readily recognized by the inequality of its thickness, the head extremity constituting a long, spirally turned thread, the lash ; the body a much stouter, shorter mass, the handle of the whip ; habitat, the caecum and its vicinity. The brownish-colored eggs, 0.05 X 0.02 mm., which are not infrequently voided in the stools, are differentiated from those of other nematoids by their double contour, strongly granulated yolk, and dis- tinct lemon shape, which is more closely simulated at both (flattened) poles by pro- jecting (shining) coverlets. The eggs are developed into mature worms in the body of man. The whipworm, which may furnish one and a half million eggs in twenty-four hours, indicating the presence of nine hundred to fifteen hundred parasites, is, according to Moosbriigger and Leich- tenstern, a frequent cause of anaemia and blood-stained diarrhoea in children. ANCHYLOSTOMA (a'yxv\o$ Gropia, fixed mouth) DUODENALIS ■ Gothard worm, from the number of cases (over one thousand reported) among the workmen in the excavation of this tunnel. — A thick, red, Fig. 43. and male Whipworm, female Fig. 44.— Eggs of entozoa: 1, 4, Taeniasagiaata; 5, Taenia lata; 6 bricoides. Distoma hepaticum; 2, Distoma lanceolatum ; 3, Taenia solium ; Oxyuris vermicularis; ?, Trichocephalus dispar; 8, Ascaris lum- round worm, female one-half to three-quarters of an inch long, male half as long ; it is distinguished by an open, oval stoma, lined with teeth, by means of which it attaches itself by hundreds and thousands to the duodenum and jejunum, penetrating even to the submucous tissue, where it sucks itself, like a leech, full of blood. It is found in Egypt, parts of Europe, South America, and Africa, whence it was imported by slaves into our own Southern States, Louisiana, Alabama, and Georgia. The oval ova, 0.05 mm. long, are voided in ENTOZOA. 45 1, male: 2, female % natural size. Fig. 45 , magnified head, showing teeth. Anchylostomum duodenale. the intestines to be discharged with the faeces and continue their growth in stagnant water, whence they are received into the intes- tine of man, in which development is completed. The symptoms, which show themselves in acute and chronic forms of anchylostomiasis, depend mainly upon loss of blood. The disease is announced in both forms with pain in the stomach and intestines, to be followed by anosmia and chlorosis. The lips and finger nails become pale, the pulse is increased in frequency, and in chronic forms there is either marked hypertrophy and dilatation of the heart or disturbance of valvular ac- tion. In the last stages of the disease anosmia becomes profound and oedema begins to show itself about the ankles and legs. Fatty degeneration of the heart, with stasis, cyanosis, and dropsy, gradually supervenes in the cases of more protracted course. The symptoms may simulate, and have been mistaken for, catarrh, ulcer, and cancer of the stomach, chlorosis, anaemia, pernicious anaemia, leukaemia, valvular disease of the heart, and malarial cachexia. The diagnosis rests upon the fact of multitudinous attack, by preference of the working classes, masons, and miners, without regard to age and sex, but with especial regard to a hot climate and bad drinking water.. Malaria is differentiated by enlargement of the spleen and liver, melanaemia, and characteristic corpuscles in the blood ; leukaemia, by affection of the spleen and lymph glands, with specific altera- tions in the blood. Certain cases of pernicious anaemia are cases of this disease. In doubtful cases the diagnosis is established by the detection of ova in the stools, generally intimately intermixed with the contents of the bowel on account of the high habitat of the worm. They are best disclosed by dilution of the faeces in water, and exami- nation of the sediment which falls over night in a conical glass. Treatment. — Thymol has proven, in the hands of Bozzolo, Grazi- adei, and Lutz, a specific in the treatment of this hitherto intractable disease. The treatment should be prefaced with a dose of calomel, gr. x., and the drug should be given in repeated moderate doses, 3 i. pro die in capsule or compressed tablet, for several days. Large doses of the fluid extract of male fern, 3 ij.-vi., if fresh and of good quality, are almost equally effective. Trichina {dpi£, rpixot, hair) spiralis (a name applied by Owen, 1835, to the immature parasite encapsulated in muscle, where it was first observed) is present in man in both the developed and 46 ENTOZOA. undeveloped states : developed, mature in the intestinal canal ; un- developed, immature in the muscles. The trichina also infests the hog, rat, cat, rabbit, fox, and guinea-pig. It is a pure parasite, the ;sole example among the entozoa, having lost all relation with the external world. The history of the trichina is wholly modern. Calcified remnants of this parasite in muscle were looked upon as dissecting-room curi- osities up to 1835, when Paget took a specimen to Owen, who gave it the very appropriate name it bears. Leidy, in 1846, discovered in a piece of ham upon his plate the same immature form, which was still regarded as an innocent wandering nematoid worm until 1860, when Zenker discovered it in myriads in the muscles of a patient who had died of a disease diagnosticated as typhoid fever, but marked by extreme pain in the muscles, with oedema of the surface, which symptoms he correctly attributed to the presence of the parasites. Virchow, Leuckart, and Zenker then demonstrated their migration from the intestines to the muscles ; and two years Fig. 46. Fig. 47. Figs. 46 and 47.— Mature trichinae. later, in 1862, Friedreich made the first diagnosis of the disease in life, with the detection of the parasite in a piece of exsected muscle. Anatomy, etc. — The mature intestinal trichina is round, elon- gated, white, and, as its name implies, extremely filiform, on which account it is barely visible to the naked eye as a fine wool hair or silvery thread. The head, formerly regarded as the tail, is drawn out almost to a line, while the caudal extremity is somewhat rounded off and is not much thinner than the body. The alimentary canal begins with a muscular mouth, is continued into an elongated oeso- phagus, expanding into a flask-shaped stomach, to be again con- tinued into the intestinal canal, which at its extremity receives in the male the opening of the seminal duct, arising from a single testicle, a thick cul-de-sac which runs along the side of the body. The female, one-eighth of an inch in length, is twice as long as the male to accommodate the ova with which it is stuffed, and which are hatched within the body and born alive. The orifice of the vagina is situated at the junction of the first and second quarters of the body. Each female may give birth, in the course of a month, to over a thousand young. The parent trichinae are short-lived. They ENTOZOA. 47 are probably, for the most part, digested and absorbed after repro- duction, as they disappear from the intestine in five to eight weeks, and are, unfortunately, not often to be found in the stools. The new-born immature trichinae, one two-hundredth of a line in length, having escaped from the body of the parent, penetrate the intestinal wall, probably by means of chemical irritation, M>"' $ % ?) f^^ to migrate, chiefly along the >ifc £[ V^HI meshes of the connective tissue, to contiguous muscles, more especially to the diaphragm, abdominal, intercostal, laryn- geal, cervical, ocular, and proximal muscles of the ex- tremities, in which latter re- gion they are crowded, as if arrested, at the tendinous ex- tremities. Here they continue to grow for fourteen days to a length of half a line, when they coil up to assume the well- known spiral form, disinte- grating the muscular tissue, expanding and thickening the sarcolemma, and, as a result of the inflammatory process thus produced, leading to the formation of a lemon-shaped capsule one-fifth of a line in length, in which they lie for the most part singly, or more rarely in groups of two, three, or even four. Thus they remain encysted alive for a year or more, exceptionally as long as twenty-five years, or become subsequently calcified — after calcification of the containing capsule — a process which begins at the poles of the cyst, but is not of necessity fatal to its contents, even when complete. Muscular tissue thus infested, when taken as food (one ounce con- taining at times fifty to one hundred thousand parasites), is dis- solved in the process of digestion, liberating from their capsules, in from three hours to three days, the muscle trichinae, which attain sexual maturity in the intestinal canal in five days, and then re- produce their species with the rapidity described. Trichinae have also been found in the blood, mesenteric glands, and peritoneal cavity. Thus the Trichina spiralis, which was formerly regarded as an accidental and innocent inhabitant of the muscular tissue, has been Fig. 48. -Young trichinae in muscle. 48 ENTOZOA. unmasked, since the first observation of Zenker in 1860 on a servant girl in the hospital at Dresden, as one of the most widely dissemi- nated and deadly of all known parasites. The symptoms of trichinosis, as the disease is called, vary ac- cording to the quantity ingested and the irritation produced. Small numbers produce no symptoms, calcified remnants having been often found in autopsies with a history of absence of any symptoms Fig. 49.— Trichina encapsulated in muscle. Fig. 50.— Calcified relics. in life. A certain stage of development and capsulation is also re- quisite to infection. Too young or insufficiently protected trichinae are killed in the stomach. Calcified capsules may not liberate their contents. The irritation, with the consequent rapid increase of peri- stalsis in childhood, often causes the expulsion of trichinae unlibe- rated from their capsules in the stools. The ingestion of alcohol in large quantities with the meal may destroy them as rapidly as they are liberated. Fig. 51.— Young trichina liberated from capsule. Fig. 52.— Encapsulated trichina. The stage of invasion, which shows itself in from three hours to three days or longer, as successive quantities may be ingested, is cha- racterized by irritation on the part of the stomach and intestines, viz., by anorexia, nausea, vomiting, tenderness to pressure, pain in the boivels, and diarrhoea. These symptoms may be absent altogether, or may vary greatly in intensity, to assume at times such severity as to be mistaken for cholera, as in the epidemic of Hedersleben in 1865, a city of two thousand inhabitants, where three hundred and thirty-seven persons were attacked, and one hundred and one died, ENTOZOA. 49 three on the sixth day. Animals fed with trichinotic flesh often succumb on the fourth day. The fever, thirst, headache, and gene- ral prostration which may accompany the local signs belong equally to other causes of intestinal irritation and are not peculiar to trichi- nosis. Characteristic symptoms announce the advent of the stage of migration and colonization in the muscles, which begins as a rule on the seventh day with oedema, functional disturbance, and pain in the muscles. (Edema shows itself first, or is noticed first as a rule, in the eyelids, disappearing in a few days and returning later in the course of the disease. This oedema is often coincident with pain, tension, and restriction of movement in the muscles of the eyes, as evidence of early invasion of these muscles ; though the pre- sence of oedema here as elsewhere, in the absence of muscular signs, has also been ascribed to the action of some toxic principle acting upon the vaso -motor system. CEdema of the face is often, that of the hands and feet more rarely, associated with that of the eyelids. Pronounced oedema of the skin over the affected muscles occurs even more constantly than about the face — is absent, in fact, in only ten per cent of cases. This cutaneous oedema also disappears for a few days, to return later. It is distinguished from the oedema of heart and kidney disease by its association with the muscular signs, as well as by the fact that it spares the genital organs, the scrotum and labia major a. Muscle symptoms appear on the ninth or tenth day as a rule, de- layed at times to the fourteenth, varying in every grade of intensity from lassitude, stiffness, or tension, to board-like indurations and most atrocious pains. The flexors of the extremities, the biceps and muscles of the calf especially, become swollen, tense, and tender, the extremities being held in semi-flexion to simulate the postures of acute articular rheumatism. Invasion of the diaphragm, abdo- minal and intercostal muscles, gives rise to dyspnoea ; invasion of the masseters, which may excite trismus, renders mastication pain- ful or impossible ; while invasion of the tongue and pharyngeal muscles may restrict or prevent deglutition, accounting thus for the rapid emaciation. Invasion of the larynx is shown by hoarseness of voice or aphonia in twenty per cent of cases, and of the ocular mus- cles by fixation of the eyeball, chemosis, and occasionally by mydri- asis and nystagmus. Impairment of hearing follows invasion of the stapedius muscle. Siveating is another common symptom of trichinosis. It occurs early, always in connection with the muscular pains, and is profuse and distressing in correspondence with their severity. It is often attended with miliaria, occasionally with herpes. Pustular erup- 50 ENTOZOA. " tions — Friedreich once found a free trichina in a pustule — acne, f urun- culosis, may follow the disappearing oedema of the face. Still another quite common as well as obstinate symptom is in- somnia, which often rapidly exhausts the patient. With this excep- tion the nervous system shows no symptoms. Though most cases are characterized by apathy or depression, the brain remains clear, except in the last stages of the severe attacks, when somnolence, stupor, or delirium may for a short time precede the end. Fever does not belong of necessity to trichinosis. Average cases show slight elevations of temperature, up to 104° F. in the severe forms, which at times present the course of remittent, or more fre- quently of typhoid, curves. Bronchitis, even catarrhal pneumonia, may result from the impeded respiration, while extensive, even fatal hypostatic pneumonia from prolonged decubitus is not uncommon in protracted cases. Duration. — The disease lasts from two weeks in the lightest cases to eight weeks in pronounced cases, and with sequelae, for the greater part of a year, in the severest forms. Kunze heard com- plaints of rheumatic pains in bad weather four years after the He- dersleben epidemic, and Kratz found weakness of the muscles in one case eight years after the attack. The mor- tality ranges from one to seventy, averaging thirty per cent. . Death oc- rrichina in muscle. curs usually from exhaustion or blood poisoning in from four to six weeks, ex- ceptionally earlier from gastro-intestinal irritation, and later from hypostatic pneumonia and marasmus. The prognosis depends largely upon the number ingested and the lapse of time. Children almost never succumb, because most of the trichinae are ejected by diarrhoea. Patients who survive the eighth week recover. Severe myositis or dyspnoea, profound pros- tration and nervous symptoms, aggravate the prognosis. Recovery is, as a rule, much more tedious and protracted than after other acute infections of corresponding severity. The diagnosis is illuminated often by the fact that others are simultaneously affected, or by the inspection of suspected pork ; possibly by the detection of mature or encapsulated trichinae, more especially after a brisk cathartic, in the mucous but not in the fluid contents of the voided stools ; positively by the discovery of imma- ture trichinae in the muscles, extracted preferably after linear inci- sion under antisepsis, from the deltoid or lower part of the biceps muscles — for the most part an unnecessary procedure. A history of gastro-intestinal irritation, followed by constipation, oedema of the EXTOZOA. 51 face on the eighth day, and muscle signs by the tenth day. with sweating, insomnia, headache, thirst, and fever, sufficiently charac- terizes the disease. Articular rheumatism, which has pain and sweating in common with trichinosis, is distinguished by the affection of the joints proper, more especially of the smaller joints, by the absence of gastro-iutes- tinal irritation, dyspnoea, insomnia, and affection of the muscles of the jaws and eyes. Muscular rheumatism selects by preference other muscles than those affected in trichinosis, and is unattended with gastrointes- tinal irritation, oedema, fever, and sweats. Grawitz, Virchow's as- sistant, declares that trichinae were found, on autopsy, in one-third of the cases of so-called muscular rheumatism. Typhoid fever is differentiated by the mental disturbance, a char- acteristic temperature curve, diarrhoea generally throughout the dis- ease, meteorism, and is not attended with oedema, asthma, and mus- cular signs. Meningitis shows herpes as a rule, hyperaesthesia, opisthotonos, a contracted abdomen, and has a different history. Finally, poly- myositis, which shows pain in the muscles, tension, deformity, pros- tration, oedema, sweats, and insomnia — in short, most of the signs of trichinosis — is distinguished by isolated attack, by the absence of history and gastro-intestinal signs, preference of the extensor mus- cles, and exemption of the diaphragm, larynx, tongue, and pharynx. Excised portions of muscle show hyaline or waxy degeneration, but no trichinae. Prophylaxis. — Xaked-eye inspection of meat does not disclose the Trichina spiralis except in cases of calcification, and calcification is not necessarily fatal to the trichinae. Putrefaction does not de- stroy them. Copious libations of alcohol with meals is a preventive as unreliable as unadvisable. Smoking and pickling, as ordinarily practised, kill only the surface trichinae. A temperature of 160° F. is fatal to the trichina, so that thorough cooking of meat offers a sure prevention of infection. A long subjection to high temperature is requisite to secure penetration to the interior of a large mass of meat of the necessary grade of heat. Therapy. — Successful therapy depends upon an early diagnosis, which is often unattainable. A brisk cathartic, calomel gr. x.-xx., castor-oil § i. , or infusion of senna, followed by irrigation of the colon, offers a hope of discharging many of the worms before the}' have been liberated from their capsules ; and inasmuch as Kratz and Cohnheim found trichinae in the stools as late as the twelfth week, it may be said that it is never too early or too late, for pur- poses either of diagnosis or of therapy, to give this method trial. 52 ENTOZOA. Recently liberated trichinae may be benumbed and more readily dis- charged by the administration of thymol, 3 i.-iss., divided in two or three doses ; or extract of male fern, 3 i.-iv. After colonization in the muscles the treatment becomes purely symptomatic. The hope of radical extermination by rapidly diffusible agents, picric acid and benzin, or water-extracting agents, glycerin and alcohol, has proven illusory. Applications of hot water, salicylic acid gr. vij., salol gr. x., more especially phenacetin gr. x., or antipyrin gr. v., every hour, may be tried in relief of pain not so great as to indicate morphine, which becomes a necessity in severer cases. Sodium bromide gr. xl., antipyrin gr. x., chloral gr. xv., may suffice to se- cure sleep, which is, however, in bad cases forced only by morphine. As the safety of the patient depends upon speedy encystment of the trichinae — a process which is hindered by motion of every kind — re- pose and quiet as absolute as possible should be enjoined and se- cured. The strength is to be sustained by alcohol and food until the force of the disease is spent. Fig. 54.— Guinea worm. Filaria Medinensis (Guinea worm). — Found frequently in Asia and Africa. A very long — sixty to one hundred centimetres — slender worm with rounded head and hooked tail ; female only known as yet, which finds some median host in minute Crustacea, with which, in drinking water, the embryo gets entrance into the body of man. It is carried by the blood vessels to the periphery, where it develops to maturity, forming furuncles and abscesses in the subcutaneous tissue, most frequently in the lower extremity near the heel. In this process it may develop gangrene or general rigors, fever, convul- sions, etc. Care must be taken in its extraction not to break it off, as it may protrude from an open wound in the skin. To avoid this accident it should be gently wound around a stick and very slowly withdrawn in the course, if necessary, of several hours. Filaria Sanguinis. — A dangerous nematoid worm found in the body is the Filaria sanguinis, first described by Bancroft, hence Filaria Bancrofti, and first recognized as a cause of chyluria by Wucherer, of Bahia (1869). The Filaria sanguinis, like the Trichina spiralis, is found in both mature and immature states in the body of man. The mature form ENTOZOA. 53 lives viviparous in the lymph vessels of the scrotum and the lower extremities, and is a parasite of the respectable length of eight to ten centimetres. The young filarise find their way from the lymph ves- sels to the blood, where they are encountered in great numbers, each worm measuring 0.35 mm. in length, with a breadth about the diameter of a red blood cor- puscle. A protruding sheath often envelops one end of it. The worm shows active sinuous motion. Manson made the curious discovery that the filarise of the blood are to be seen only at night, whence the failure which has marked many attempts at their discovery during the day. Fluids must also be examined fresh. Some intermediate stage of development must exist between the mature filaria in the lymph vessels and the imma- ture filaria in the blood, outside the body, else various transition forms would be seen. There is reason to be- lieve that the animal or insect which officiates in secur- ing this transition state is the mosquito. The mosquito sucks itself full of blood containing the filaria and carries it to water, whence the mosquito arises, so that the body of man be- comes the host of the work through the medium of drinking water. Fig. 55.— Filaria sanguinis. Fig. 56.— Filariae in blood vessels. Fig. 57.— Elephantiasis cruris lym- phangiectatica (Ziegler). The Filaria sanguinis is a dangerous parasite, in that it produces symptoms in both stages of development. In the skin it causes 54 ENTOZOA. sclerosis, elephantiasis, occlusions of the lymph vessels, lymphan- gitis, lymphangiectasis, and ruptures. In the blood and lymph ves- sels it may lead to occlusions, dilatations, and ruptures, with escape of lymph, sometimes of blood. The curious condition known as chyluria, from rupture of lymph vessels into the bladder or renal pelvis, is found to depend in many cases upon the Filaria sanguinis. The urine in these cases looks like milk, and may contain as much as three per cent of fat. Haematuria also, but more infrequently, arises from the same cause. Prophylaxis is simple. It consists in thorough boiling of all drinking water, from whatever source. Perfect filtration would be equally effective. ]STo known remedy may reach this parasite in the tissues or in the blood. It has been suggested that the picro-nitrate of potash, on account of its highly diffusible properties, might be of benefit. Treat- ment is really wholly symptomatic. The tincture of iron is indicated, gtt. xxx. ter in die. Lewis recommended gallic acid. Fig. 58.— Liver fluke. Liver Fluke. — Of the trematoid {rpr/fia, foramen) worms, the only example of particular interest to the practitioner of medicine is the Distoma (double mouth) hepaticum, or liver fluke. The liver fluke is, as the name implies, a flat, somewhat triangular worm about an inch long and half an inch wide. The somewhat elongated head terminates, or begins, in an oval sucker, below which on the ventral aspect is another sucker, which orifices have given the worm its place. Between the two suckers is the genital orifice. The yellow- ish, oval eggs are among the largest found in the faeces. The liver fluke is encountered rarely in man, more frequently in the ox, deer, occasionally in the horse and hog, by far mOst fre- quently of all in the sheep, where it causes the disease commonly known as the rot, which kills annually thousands of sheep. The development of the liver fluke is a strange story. The eggs escape with the bile into the intestine, whence they eventually reach ENTOZOA. 55 water, and, being provided with a ciliated envelope, swim about freely until they come in contact with the body of a snail, which they pene- trate to become lodged in its interior. Here the embryo, losing its ciliated envelope, becomes converted into a cyst, which produces on its interior elongated bodies called nurses. The nurses penetrate to the liver of the snail, where are developed neAv forms somewhat of the shape of the parent fluke, called cercarias. The cercarias escape from the nurse and the body of the snail into the water, and, being pro- vided with a long tail like a tadpole, swim about actively for a time until they become attached to subaqueous grasses, when they lose the tail and become quiescent. Thence, in the grazing of sheep, they may be reconveyed to their bodies to find a way to the liver and develop to sexual maturity. Fig. 59.— Distonia haematobium with ova. Male in gyneecophoric canal of female. The liver fluke is rarely found in the body of man in such num- bers as to cause occlusion, dilatation of the bile ducts, and reabsorp- tion of the bile, with the serious complications which result from this condition. The paucity of their number in man protects him against disastrous consequences. Prevention is the avoidance of subaqueous vegetables, such as watercresses, to which the bodies of snails are attached, and of impure drinking water. The Distoma Haematobium is found in the portal vein, in its trunk and derivative branches, in the body of men and apes. The ova, deposited in the mucosa of the ureters, bladder, etc., develop em- bryos which produce ulceration in these structures. This parasite is frequent in Egypt and Abyssinia, but has not been seen elsewhere. OHAPTEE III. BACTERIA. The term bacteria (fiaxrpov, a rod) applies collectively to a large* class of micro-organisms, the study of which is known as bacteriology. These bodies constitute the simplest and lowest forms of all living things. From their mode of propagation — by fission — they fall in botanical classification under the division of schizo- mycetes (v\rf, a bunch of grapes). A coccus or bacterium whose length is greater than its diameter — i.e., an oval micrococcus — is a bacillus. Spirilla are curved bacteria — with one curve, like a comma, the vibrio ; or with BACTERIA. 57 Fig. 60.— Bacilli stained to show vibratile cilia and flagella (after Zettnow) 58 BACTERIA. successive curves, like a corkscrew, the spirochsete. Bacteria vary greatly in both length and breadth, but are, for the most part, so- small as to be on the confines of the visible, even with the micro- scope. The mass of micro-organisms are innocent to man. The bacteria Fig. 61.— Streptococcus. Fig. 62.— Spirochetes of relapsing fever. of putrefaction return to earth and air everything that has ceased to- live, so that life would soon become impossible without them. It is only under certain circumstances that the bacteria of putrefaction may prove injurious. Innocent micro-organisms injected into the body, even in mass, do no harm. They fail to find necessary condi- tions for development, and perish. Fig. 63.— Sarcinae. Fig. 64.— Yeast plant. Fig. 65.— Bacillus pneumoniae (Fried- lander) with gelatinous envelope. Pathogenic micro-organisms vary in length from one to forty (1-40 pt) micromillimetres, and in breadth from 0.5 to 7 yu. 1 Many micrococci are too minute to admit of accurate measurement. The largest micro-organism is the spirillum, which may reach a length of 1 An jn (mikron) BACTERIA. 59 0.2 of a millimetre. Perhaps a better idea of size can be conveyed by comparison with a similar object. The bacillus tuberculosis, which occupies in respect to size a median place, varies in length from -j-gVir *° 3^00 °f an inch, the smaller measurement being the average diameter of a corpuscle of human blood. Many species are endowed with motion, gyration, sometimes with address and agility, rotation and oscillation, flexion, extension, and locomotion. The ba- cilli of tuberculosis and milzbrand, together with all micrococci, have no motion at any time. That tremulous, molecular motion — the so-called Brown's motion — in the same place, observed also in inorganic matter, is to be distinguished, of course, from individual motion. Motion is often secured to micro-organisms by means of vibratile cilia, though most bacteriologists believe it to be a property innate or inherent to the protoplasm. Bacteria multiply by division (fission) — that is, by increase in size and separation into two (the cholera vibrio splits in two in fifteen to forty minutes) — or by the formation of spores, spherical bodies which elongate to form bacteria. Micro- cocci multiply only by division, and spores have not yet been distinctly demonstrated in spirilla. Bacilli form spores in two ways : by devel- opment in their interior, with sub- sequent liberation on rupture of the n .-,-, j iii Fig. 66. — Bacilli tuberculosis, showing bacillus — endospores ; or by devel- opment at an extremity, which falls away to constitute a new individual — arthrospores (apdpov, a joint). Endospores are much more tenacious of life than the bacillus, or than the arthrospore, which is endowed with no particular resistance. Hence endospores constitute what are known as permanent forms. In either case the protoplasm of the bacillus clears up at the point of formation of the spore, to assume the shape of a minute drop of greater diameter, at times, than the bacterium itself. Bacilli filled with spores, which may exist to the number of three or four, show a checkered or beaded surface. The activity of formation of spores is an index to the degree of nutrition. The liberated spore soon breaks the spherical surface with a point, which gradually elongates to form, in turn, the perfect bacillus. Spores may be recognized by their glistening, highly refracting contour. According to the mode of nutrition bacteria are divided into sap- rophytes ((ja7tp6^ } rotten), which live on dead soils, and parasites 60 BACTERIA. (napaairos, feeding with or on), which live on living matter. Pa- rasites are also divided into obligates — that is, pure parasites — and facultatives, which may live both as parasites and saprophytes. Bacteria are again divided, according as they may live with or without oxygen, into aerobes and anaerobes. Here, too, there are ob- ligate aerobes, which can live only in the presence of oxygen, and obligate anaerobes, which can live only in the absence of oxygen. And here, too, there are facultative anaerobes, which may live in the presence of oxygen. Saprophytes thrive best at a temperature of 20° to 25° C, para- sites best at 35° to 40° C. Every micro-organism has its own pe- culiarities regarding temperature. Sunlight destroys all micro-or- ganisms ; even the most tenacious spores or permanent forms perish under the direct rays of the sun in the course of a few days. Bacteria are invisible not only because of their size, but also be- cause of their lack of color, and are rendered visible by various stains or dyes. For this purpose the best materials are the acid and basic aniline dyes, especially methylene blue and violet, gentian violet, Bismarck brown, f uchsin, and, of the acid anilines, eosin and acid fuchsin. They are usually prepared as follows : Alkaline methylene blue solution (Loffler) : Concentrated alco- holic methylene blue solution, thirty cubic centimetres ; liquor po- tassa? (1 : 10), one hundred cubic centimetres. Aqueous aniline dyes (Ehrlich) : Aniline oil, four cubic centimetres, thoroughly agitated with water, one hundred cubic centimetres, fil- tered after deposit ; whereupon is added concentrated alcoholic solu- tion of fuchsin or methylene violet up to distinct opalescence. Carbolic-acid-fuchsin (Ziehl-Neelsen) : Distilled water, one hun- dred ; crystallized carbolic acid, five ; alcohol, ten ; fuchsin, one. Iodine-potassium-iodide solution : Iodine, one gramme ; potassi- um iodide, two grammes ; distilled water, three hundred grammes. For use the solution is diluted to a Madeira color. The most generally employed is the carbol-fuchsin solution. The various micrococci, staphylococci, streptococci, FrankeVs diplococci, cholera vibrios, recurrent fever spirilla, and nearly all the pathogenic micro-organisms of man, as well as most of the saprophytic bacteria, are quickly and distinctly stained in this way. A large drop of this solution, let fall upon the object glass from a pipette and heated a few seconds to half a minute, suffices to color all bacteria distinctly. A few forms with dense membranes must be heated a whole minute. Bacteria are prepared for color, if in water or bouillon free of fat, by simply washing in water ; but, if in an albuminose fluid (blood, pus, or oedematous fluid of pneumonia) the cover glass should be dipped in absolute alcohol ; if in fat (milk or oedema of connective BACTERIA. 61 tissue), the cover glass, after drying and before heating, should be placed a short time in absolute alcohol and ether. In. this way are colored not only the bacteria but also all protoplasm in the field. A valuable solution, especially in differential diagnosis, is that of Gram, which is prepared as follows : To ten parts of aniline water (i.e., the milky fluid which results from the agitation of four parts of aniline oil with one hundred parts distilled water) is added one part concentrated alcoholic gentian violet solution. The mixture is then passed through a filter moistened with water. The object glass, after drying and heating, is floated upon this stain five to fifteen minutes, sometimes under heat, and is then, without washing, ex- posed at least five minutes to the iodine-potassium-iodide solution. The blue-black color thus imparted is decolorized in first weak, then stronger, but not absolute, alcohol to a pale gray or yellow. Here- upon the specimen is dried in the air and examined under the oil of cedar or conserved in balsam. By the method of Gram all cell ele- ments are decolorized, while the bacteria maintain their dark-blue stain. Thus are colored the pneumococcus of Frankel, the strepto- coccus of erysipelas and acute suppuration, the staphylococcus of pus, the bacilli of anthrax, the mycelia of actinomyces, and the bacilli of tuberculosis. But the method of Gram will not color Friedlander's pneumonia bacillus, the typhus bacillus, the gonococcus, or the chol- era vibrio. As they are but indistinctly colored in this way, tubercle bacilli require special treatment. A particle of sputum compressed between two coloring glasses is spread out by the separation of the glasses. The specimen is then dried by the passage of the glass, held with forceps, about as fast as cutting bread, three times through a flame, specimen side up. The cover glasses are then dropped upon the ani- line water solution with f uchsin or gentian violet, or heated in this solution until vapor arises, then decolorized in a solution of nitric acid (1:4) and alcohol (sixty per cent). An aqueous solution of methy- lene blue or Bismarck brown furnishes the after-stain ; or, by a shorter method, the cover glasses or sections are colored in carbol- fuchsin, and then brought for one minute into a solution of water fifty, alcohol thirty, nitric acid twenty. Spores may not be colored after these methods, as their firm en- velopes prevent penetration. This resistance is overcome by subjec- tion to heated steam for an hour, or by passage seven to ten times through a flame. Bacteria are isolated and are further and much more positively distinguished by cultivation in certain soils. The first experiments in cultivating bacteria were made in fluids, solutions of meat, beef tea, chicken soup, malt extracts, infusion of hay, etc. ; but fluids are open 62 BACTERIA. to the objection that they admit other germs to coalesce with, and <>, . ^ „.. „ render impure, the special variety to be studied. _ y r i ' ,." 5^ Pure cultivations became possible only with the use of the solid culture soil first employed by v {, Koch. Germs falling upon a solid surface remain 5 § - : '■:W I 'I u S% ; Fia. 68.— Scale surface culture (serum) of tubercle bacillus. Fig. 69.— Nail stick culture (gelatin) of pneumococcus. fixed in the same place. The solid culture soil made practicable the absolute isolation of germs, without which accurate investigation is impos- sible. Koch made his first studies with the com- mon potato. The potato was the key to the whole subject of solid cultures. What the apple was to Newton the potato was to Koch. Subsequently gelatin was employed, - Fig. 67.— Bacillus Hava niensis (Sternberg). BACTERIA. 63 then aqueous humor, then gelatinized meat preparations, peptonized gelatins, etc. , and, as a climax, gelatinized blood. Thus has been determined the peculiar soil in which the varieties of pathogenic bac- teria thrive best. Moreover, it is seen that the colonies in their growth assume different forms or shapes, or exercise different effects upon the soil. Different bacteria vary also in the degree in which they fluidify the semi-solid substance of their soil. Lastly, pathogenic bacteria are distinguished by their physiologi- cal effects. From any special successive generation of a special variety of bacteria, material may be selected for introduction into the body or blood of various animals. Bacteria, or their products in culture soils, are introduced into animals by ingestion with food or by means of the oesophageal sound; by inhalation or insufflation of atomized matter; by intraperitoneal, intraocular, or intravenous in- jection, as into the external jugular or (in rabbits) posterior auricular veins ; lastly, by subcutaneous injection with the disinfected syringe, or by subcutaneous insertion with the platinum needle, usually into slight wounds of the skin, under thorough asepsis. Pathogenic micro-organisms act in two ways: by intoxication and by infection. Intoxication is a poisoning by products of micro-or- ganisms produced outside of the body ; infection is poisoning by products produced by bacteria inside the body. These sources are •sometimes distinguished as ectogenic and endogenic — terms destined soon to substitute miasmatic and contagious as applied to infectious disease. Intoxication is caused by the saprophytes, which may pro- duce ferments in food, as in meat, fish, sausage, milk, and cheese. The ferments may be infective even after destruction of the micro- organisms which caused them ; so food, even though cooked, may produce disease. The causes of infection are the pathogenic micro- organisms which multiply inside the body and evolve chemical products. The fact that pathogenic micro-organisms are not ab- sorbed proves that they produce disease by some chemical change. Moreover, the character of the sjinptoms — sopor, stupor, coma, delirium — which supervene in cases of grave acute infection speaks in favor of this view and against the belief that bacteria act mechanically or by the mere abstraction of oxygen. The only hitherto known poisons which may, in minute quantities, induce such grave toxic signs are the poisons resulting from the action of the bacteria of decomposition upon organic matter. As these intense^ virulent poisons were first observed only in dead organic matter, they were called ptomaines (7tTGopia, the fallen, a corpse ; hence more properly ptomatines). As many ptomaines are perfectly innocent, the term has been better substituted by Toxines. The toxines are nitrogenous, basic compounds, like the vegetable alkaloids, of complex com- 64 BACTERIA. position. Among the non-poisonous ptomaines there have been extracted, in all cases from decomposing dead bodies, neuridin, cadaverin, putrescin, and cholin. Poisonous — i.e., toxiues — are: peptotoxin, present in many peptones ; neurin, in decomposing meat ; muscarin, the poison of the fly fungus, found also in decom- posing fish. From pure cultures of pathogenic bacteria have been extracted a toxine from the typhoid bacillus— typhotoxine ; from cultures of the tetanus bacillus and the amputated extremity of a man dead of tetanus, tetanin and tetanotoxin. Besides the pto- maines or , toxin es there are to be found certain albuminoid bodies, ^products of micro-organisms, with similar poisonous but very differ- ent chemical properties, which are known as toxalbumins. Such toxalbumins have been separated from cultures of the diphtheria, typhoid, and tetanus bacillus. Animals, including man, vary in susceptibility to the action of micro-organisms and toxines. Certain animals are more, certain animals are less, liable or susceptible to contract or be inoculated with a disease. These animals are said to be, one predisposed to, the other endowed with, immunity to these diseases. The disposition to a disease may be natural — i.e., inherent — or acquired. Natural immunity may be overcome in various ways. Starvation makes pigeons susceptible to anthrax. The injection of papayotin leads to the appearance of hitherto latent micro-organisms to such degree, according to Bibbert, that the heart's blood will be thick with them in two hours; that is, the introduction of a vegetable ferment so profoundly alters the condition of the blood as to make of a hitherto sterile a fertile soil. So, also, certain ptomaines will reduce all en- ergy to such an extent that bacteria hitherto innocuous become infec- tious. According to Rogers, the immunity of rabbits to rauschbrand is overcome by the introduction of the innocent Bacillus prodigiosus. Guinea-pigs immune to chicken cholera are rendered susceptible by the injection of hydracetin or pyrogallol, substances which dissolve red blood corpuscles; and the addition of phloridzin, which causes a toxic diabetes, discharges the immunity of white mice to glanders. Hunger makes pigeons, naturally immune, susceptible to milz- brand. Fatigue acts in the same way with other animals. Thus white rats made to walk a wheel continuously for seven days lose their immunity. Temperature plays a similar role. Frogs kept at a temperature below 28° C. will not contract the disease, but will inevitably succumb to it at higher grades. Hydraemia lessens the susceptibility of rabbits to the staphylococcus by eliminating toxines through the kidney. Here is a hint regarding the value of free libations of water in the treatment of typhoid fever and other infec- BACTERIA. 65 tions of man. Staphylococci injected into the peritoneal sac are re- sorbed without damage, unless the peritoneal endothelium be injured or diseased. Lipari found that the intratracheal injection of the sputum of pneumonia did no damage unless the animals were ex- posed to cold, which probably acted by producing catarrhal swelling and paralyzing ciliary motion, to permit the retention of bacteria. The so-called " mixed infection" occurs in this connection. Tuber- culosis admits the organisms of sepsis, as does also diphtheria. The organisms of measles and pertussis prepare the soil for tuberculosis, etc. The problem of medicine in the prevention and cure of disease is the reverse of this process, to wit, to confer immunity in lieu of lia- bility. Artificial immunity is conferred in various ways : 1. By increas- ing cell energy to resist the invasion of disease. Phagocytosis is an exemplification of this process. Healthy cells incorporate, digest, Fig. 70.— Trichomonas intestinalis. Fig. 71.— Naked amoebae coli. Fig. 72. — Cercomonas intestinalis. and destroy micro-organisms ; feebler cells yield before them. 2. By previous attack of a disease, as in inoculation of variola. 3. By inoculation of a milder form of the disease with attenuated micro- organisms or matter, as in the case of vaccinia and hydrophobia. 4. By inoculation of substances extracted from the blood (serum) of animals which enjoy natural immunity, or to which immunity has been conferred. These principles may be also extracted from the milk (Ehrlich). 5. By inoculation of matters extracted from culture soils in which specific micro-organisms have been developed. Substances extracted in this way from the blood, milk, or from culture soils are known as antitoxines. Such antitoxines have been already found in tuberculosis (tuberculin), pneumonia, diphtheria, glanders, hydrophobia, tetanus, and typhoid fever. Future specific therapy lies in the direction of the discovery and perfection of anti- toxines. Protozoa are the very lowest forms of animal life. They are mi- nute masses of protoplasm of various shape ; sometimes naked, gene- 5 66 BACTERIA. rally invested with a membrane ; sometimes enclosing pigment mat- ter and vacuoles, and sometimes ciliated, flagellated, etc. How protozoa find entrance into the body of man is as yet unknown, but they are certainly encountered in the blood, in various juices, or- L Pig. 73.— Plasmodium malariae : a, 6, c, intracorpuscular bodies; g, crescent; h, flagella. gans, and tissues of the body, epithelium, and, in some cases, defi- nitely in connection with certain diseases. Protozoa are divided, according to their modes of motion, nutri- tion, etc. , into three groups — the rhizopods, sporozoa, and infusoria. Rhizopods are, for the most part, naked — i. e. , membraneless — masses of protoplasm, with digital or filiform protrusions (pseudopods) to surround and incorporate food or foreign bodies, as in the amoebae, which belong to this group. Infusoria possess permanent cilia, by which they secure motion and ingest food into an oval orifice. Both infu- soria and rhizopods live on solid or semi-solid food. Sporozoa are covered by a cuticle having neither pseudopodia nor cilia, and are nourished wholly by osmosis. Sporozoa multiply by hard- shelled spores produced in the interior of the body. Perhaps the best-studied example of disease produced by protozoa is mal- aria. Blood withdrawn from any part of the body, especially from the spleen, but most conveniently and safely from the end of the finger, shows in this disease such masses of protoplasm, sometimes granular, sometimes crescentic, very often irregular, as to enable the practitioner in a doubtful case to declare the existence of the disease and differentiate it from simulating maladies. As these Fig. 74.— Coccidia from the human liver: A X 330, B and C X 1,000 (Leuck- art). BACTERIA. 67 bodies are to be found in all cases of malaria, and not in any other disease, increasing during fever, disappearing after the administra- tion of quinine or other antiperiodic, and as the inoculation of blood containing them conveys the disease, they are regarded as the specific cause of malaria, notwithstanding the fact that they have not yet been cultivated outside of the body. Protozoa belonging to the group coccidia have been recognized by Nisser in the nodules of molluscum contagiosum, a disease of the skin. The failure to ^-S^> Fig. 75.— Scirrhus of the breast and small (Foa). epithelium enclosing protozoa, black stellate bodies, large discover micro organisms of other nature, and the recognition of pro- tozoa in these affections, have awakened the suspicion that certain exanthemata, also dysentery, abscess of the liver, cancer, etc., may depend upon, or be associated with, this cause. Pfeiffer depicts sporules found in the interior of the vesicles of herpes zoster, which is now regarded as an infection, also similar structures in varicella and variola vera ; and Yan der Loof finds cell forms — plasmodia — in the vesicles of vaccinia. CHAPTER IV. INFECTIOUS DISEASES. Up to the" present time it is definitely known that micrococci pro- duce pyaemia, septicaemia, furunculosis, acne, erysipelas, gonorrhoea, trachoma, pneumonia ; bacilli cause anthrax, diphtheria including croup, typhoid fever, tetanus, tuberculosis, lepra, glanders, measles, and typhus fever ; spirilla produce cholera and relapsing fever ; sporozoa cause malaria. Regarding other infections the evidence is not so positive ; in some cases it is probable, in others as yet only presumptive. SEPTICAEMIA, PYAEMIA, SEPTICOPYEMIA. Septicaemia ((?rj7rr6? P poisonous); Pyaemia; Septico-pyaemia. — In- fection (intoxication) of the blood and body by ferments, toxines, products of the various pus-producing micro-organisms, characterized by chills, high fever, profuse sweats, joint affections, metastatic de- posits, haemorrhages, diarrhoea, and nervous symptoms. These affections, which were formerly considered separate, are now known to be due to the same cause and belong properly together. Predominance of general signs of blood poisoning — i.e., nervous signs, high fever, etc. — in the absence of metastatic deposits, consti- tutes septicaemia ; predominance of metastatic processes, haemor- rhage, abscesses, etc., constitutes pyaemia; conjunction of the two sets of signs constitutes septico-pyaemia. Numerous micro-organisms produce pus and act as causes of this condition. 1. One of the most frequent is the Staphylococcus pyo- genes aureus, which, cultivated on gelatin or agar, shows, after ex- posure to light, gold-yellow colonies. Smaller numbers localized pro - duce in the skin acne, furunculosis, and subcutaneous abscesses; in the interior of the body, suppurations of bones and joints, of the lungs, pleura, liver, heart (endocarditis), and kidneys. The staphylococcus abounds in the air of crowded rooms. 2. The Staphylococcus pyo- genes albus, which forms white colonies. 3. The Staphylococcus pyo- genes citreus, which forms lemon-yellow colonies. 4. The Micrococcus pyogenes tenuis, which forms perfectly clear colonies. 5. The Strep- SEPTICAEMIA, PYAEMIA, SEPTICOPYEMIA. 69 tococcus pyogenes, which grows in chains of four, ten, or more mem- bers. The streptococcus has a much greater tendency to spread and to give rise to extensive phlegmonous processes. The various micro-organisms or their products, sometimes both, Fig. 76.— Pus from an acute abscess: a, pus corpuscles; 6, diplococcus; c, streptococci; d, set of four, tetrads (Woodhead and Hare). are introduced through breaks of the surface, wounds (parturient or puerperal uterus, etc.), or upon the heels of other micro-organisms in a'"" Fig. 77.— Septic infection of pectoral muscle after a " post-mortem " wound of the hand : a, perimysium with streptococci; b, cross section of unaffected muscle fibre ; c, cross section of af- fected fibre ; d, fibre penetrated by streptococci. the course of specific disease, tuberculosis, variola, dysentery, to cause a mixed infection or constitute the terminal link in the chain of disease process. 70 SEPTICAEMIA, PYEMIA, SEPTICOPYEMIA. Sometimes the avenue of entrance may not be seen or discovered. Poisonous matter may be introduced from the lungs, intestine, or other recess, to give rise, in light cases, to the symptoms of a " bad cold," dyspepsia, or rheumatism, or in bad cases to a pleuritis, ulce- rative endocarditis, etc. A searching investigation will sometimes discover the source of such infection at the prostatic urethra, ileo- caecal valve, interior or adnexa of the uterus (salpingitis), etc. Certain cases defy detection. These cases of concealed Origin are very appropriately called cryptogenetic sepsis — a term much more conducive to inquiry than "idiopathic" or "spontaneous," which rest upon entirely false conceptions. Symptoms. — The disease, considered as a septico-pyaemia, is ush- ered in suddenly in the course of puerperium, after a traumatism, operation, or in the midst of appa- rent health, with a chill or series of chills, followed by high fever, head- ache, vertigo, perhaps vomiting, and usually with well-marked nervous de- pression. The patient soon complains of pain in the region of the joints, which" are sometimes swollen and ten- der. The spleen swells early. Some- times there is icterus in light form from duodenal catarrh, in rarer (hematoge- nic) form from dissolutio sanguinis. The fever is continuous, subject to remissions, usually with evening exa- periodicity, but with periods of great The surface is cold mmm :;iss? s: nun Him i win mi SKK SSSIHS?.. SSiS Si HHHP ...... Ilfll Fig. 78.— Temperature in a fatal case of sepsis. cerbation, with no distinct elevation (106° F.) followed by profuse sweats. and clammy. The hectic and night sweats of tuberculosis are really septic. The pulse is enormously quickened, is soon irregular and reduced in force. The patient falls into a typhoid state, with low, muttering delirium. Metastatic affection shows itself — in the skin as scarlatiniform rashes, herpes, pustules, pemphigus, petechiae, or larger haemorrhage, abscesses ; in the eyes as haemorrhage of the retina, irido-choroiditis, panophthalmia ; in the heart in irregular action, bruits mostly mitral, friction sounds of pericarditis, dyspnoea ; in the kidneys as albuminuria, haematuria, casts ; in the brain as embolic deposits, abscess, and haemorrhage. Diagnosis. — The disease must be differentiated from : 1. Typhoid fever, which has in common with it fever, diarrhoea, spleen tumor, and petechiae. Typhoid fever begins more slowly, is attended with mental dulness from the start ; the fever is more typical. Herpes, joint affections, mitral lesions, retinal haemorrhage, do not belong to SEPTICEMIA, PYEMIA, SEPTICOPYEMIA. 71 typhoid fever. 2. Miliary tuberculosis, in which may be often dis- covered a local depot of tuberculosis in the lungs, lymph glands, spine, hip, etc. Meningeal tuberculosis is usually preceded by evi- dence of local infection in the way of bronchial and intestinal catarrh. 3. From rheumatism, which has in common sweats and affection of the joints, but which has not successive chills, metastatic abscesses, affec- tions of the skin, eye complication, etc. 4. Cerebro- spinal meningitis also occurs suddenly, but prefers winter, soldiers, children, and shows with no, or much less, or more irregular fever, hypersesthesia, opisthot- onos, constipation, etc. o. Malaria shows more distinct fever, with quotidian or tertian periodicity, and is jugulated by quinine, which has no real control over pyaemia. The discovery of the Plasmodium in the blood of malaria, as well as of the typhoid bacillus in the spleen of typhoid fever, has already cleared up doubtful cases. Ulcerative endocarditis is itself evidence of septico-pysemia. The prog nosis is always grave, though it varies according to the range of the disease. Light cases readily recover. High fever, pro- fuse sweats, severe nervous signs are always grave. Metastatic deposits are ominous, though not of necessity fatal. Recovery has occurred even after affection of the eye. In every severe case recov- ery is tedious and protracted. Treatment. — Prevention is easier than cure. Modern methods of asepsis shut out entrance of pus micro-organisms to large extent and thus at least prevent the epidemics of former times. Prophylaxis pays scrupulous regard to dressings, instruments, personnel, etc. Depots of infection are excised or laid open and washed out. Mem- bers may require amputation, the interior of the uterus curetting. Wounds are dressed with antiseptics — sublimate solutions one per cent, carbolic acid five per cent. Rutter recommends: ^ Iodoform 1 part. Ether 2 parts. Alcohol .' 8 parts. M. as a disinfectant wash, to be applied thoroughly into every crevice and recess of a wound. The actual cautery, Paquelin's thermo- cautery, galvano-cautery, furnish at times the finest results. In cryptogenetic cases everything depends upon the discovery of and destruction of the cause. A slow sepsis of months' duration has been stopped at once by the deep urethral injection with the Ultzmann catheter of a strong solution of nitrate of silver, gr. xx.- § i. ; and dangerous signs have disappeared after extirpation of a diseased ovary, after a laparotomy, trephining a mastoid process, etc. Drugs can do but little. Quinine in round dose, gr. v. every two to four hours, may help a simple case. The antipyretics are not 72 ERYSIPELAS. much indicated in the treatment of a long fever whose cause is un- discoverable or ineradicable. The body may be saturated with sub- limate, small doses frequently repeated, one thirty-second grain every hour or two, or with creosote thirty or forty drops a day, as in the treatment of tuberculosis. It may become necessary to give opium to relieve pain or secure sleep. The only real address to the cause of the disease is in the exhibition of alcohol in the form of whiskey or brandy in large and frequently repeated doses. It is difficult to get the toxic effect of alcohol in a case of septicaemia. Alcohol feeds the body, lowers the temperature, and, to what extent it may, neutralizes the ferments and toxines of septicaemia. When the patient can no longer take alcohol the outlook is bad. ERYSIPELAS. Erysipelas (spvoo, to draw ; synonym, i'Xxao, e'kxos, wound ; Latin, ulcus, ulcer; 7t£\a$, near; Latin, prope ab aliquo loco, i.e., to spread; also, ipvdponekaS, epvaos, epvOpolj Latin, ruber, red; neXXa, pellicle, skin, vide Stephanus, " Thesaurus linguae Graecae"; whence in the sixteenth century the German Rothlauf, Rose, Wund- rose). — A specific acute infection of the surface of the body, always of local origin, and implying always a present or previous break of the surface, caused by the Streptococcus erysipelatis, marked by in- tense inflammation (pain, heat, redness, and swelling), high fever, gastric and nervous distress, a tendency to spread, and a liability to mixed infection (suppuration, phlegmon, gangrene), short duration, and in uncomplicated cases a restitutio ad integrum. History. — Erysipelas received its name in the most remote an- tiquity, and was, in the earliest history of medicine, associated with wounds of the surface. Yet this association was not considered a necessity in ancient times. Hippocrates recognized an idiopathic as well as a traumatic erysipelas — a distinction which found advocates up to the most recent times. This so-called erysipelas verum, s. spontaneum, the medical, as distinguished from the erysipelas spu- rium, s. traumaticum, or surgical form, was in the humoral pathol- ogy an inflammation of the skin excited by the escape of ' ' peccant matter" in the blood. Although Hippocrates and his followers included under the term many processes, suppurative, phlegmonous, gangrenous, etc., which we now consider complications, he had? nevertheless, a clear idea of the character of the disease. " In many cases," he says ("Epidemics," book hi., 4), "erysipelas, from some obvious cause, such as an accident, and sometimes from a very small wound, broke out all over the body . . . great inflammation took place, and the inflammation quickly spread all over . . . but ERYSIPELAS. 73 these tilings were more formidable in appearance than dangerous, for when the concoction turned to a suppuration most of them recovered." The first vague intimation of the true cause of erysipelas is due to the penetrating insight of Henle (1840), the real pioneer of para- sitism, who maintained that it was introduced by the invasion of the lowest forms of vegetable growth, which were invisible because they could not be distinguished from tissue cells ; but the first distinct clinical exposition of the mode of origin of the disease belongs to Trousseau (1848), who insisted that even the medical, so-called non- traumatic cases " have almost always a starting point, which, though it cannot, strictly speaking, be called a wound, is at least a lesion, a small lesion of the integument at some point on the face [or else- where] , such as the corner of the eye, the nose, the lips, behind the Fig. 79.— Erysipelas cocci in the cutis (Eichhorst). ear, or on the hairy scalp." Specific micro-organisms had been claimed as the cause of erysipelas by Nepveu (1870), Hueter, Billroth and Ehrlich, Klebs, Orth, Tillman's and Wolff (1880), for the most part in the blood, but were first definitely discovered in the skin by Koch (1881), who observed them as chain-forming cocci, streptococci, exclusively in the lymph vessels and adjoining lymph spaces, but never in the blood vessels. Fehleisen (1881), independently of Koch, made the same discovery, and by isolating, cultivating, and inocu- lating the micro-organism in man for therapeutic purposes, as well as in the lower animals, confirmed his conclusions and established for all time the nature of the disease. Etiology. — The erysipelas coccus develops in serpentine form, as a bead or chain coccus, whose individual members, though very small, vary somewhat in size. It thrives in all kinds of culture soils, gelatin, agar, blood serum, milk bouillon, as well as upon the surface ■of the potato ; with and without oxygen equally well ; best at a tem- 74 ERYSIPELAS. perature of 30° to 37° C, but also at room temperature if not too low. It differs in no visible way from the pus streptococcus (Streptococcus pyogenes). Whether or not it is the same organism remains as yet an open question. Should it prove to be so, the suppurative and phlegmonous processes so often observed in erysipelas would be ex- plained by invasion of structures — viz., the loose subcutaneous tissue — which offer less resistance than the skin. It is found in greatest abundance in the zone of tissue just beyond the region of deepest redness, still uncolored by the inflammatory process. The lymph vessels and spaces of the skin, and later of the subcutaneous connec- tive and fatty tissues, are crowded to occlusion and distention by quickly multiplying streptococci, which have disappeared already from the visible zone of inflammation, either by reason of the short life of the organism or of consumption (incorporation) by the tissue cells and phagocytes, and not on account of the high fever they ex- cite, as they continue to develop at 40 o C, but with difficulty at 43° C, to perish in twenty-four hours at 48° C. (118° F.). They seem to perish rapidly in the blood, as they are not found in Fig. 80.-Streptococcus erysipelatis : colony in the blood vesse l s though the pOS- a lymph vessel, ear of rabbit, two days after in- . . , . ocuiation(Ziegier). sibihty of metastasis in this way is proven by exceptional cases of intra-uterine (fetal) infection. Lebemeff found them in a section of skin of a child dead of the disease ten minutes after birth. Though Eiselsberg and Emmerich collected them from the air of surgical wards and operating rooms, as disseminated from particles of des- quamated skin, there is reason to rank the erysipelas coccus with the class of saprophytes, as similar cocci are discovered in various decom- posing matters, so that the parasitism of man 4 s an accidental inva- sion. Hajek claims that the body of man is not a very favorable soil for the growth of the erysipelas coccus, inasmuch as it is carried only by the lymph vessels, whereas the coccus of pus (phlegmon) develops, independently of lymph vessels, in every direction. Brieger and Was- serman dialyzed from the urine of a patient affected with consecutive nephritis a toxalbumin fatal to mice and guinea pigs. With resolu- tion of the erysipelas and nephritis the urine ceased to be poisonous. Age, sex, season, soil, have no influence in the production of the disease, which owes its origin exclusively to a specific cause, and which, once established in a house or institution, may develop upon the surface of an}', even the most trivial, break of the surface — mere abrasions, leech bites, old granulations, slight fissures, etc. — in a sus- ceptible individual. Vaccination had to be suspended in Boston in 1851 on account of the frequency of erysipelas infection — an accident ERYSIPELAS. 75 put beyond the suspicion of a mere sequence in the experience of Doepp, who infected every one of nine children by the use of lymph from a child that showed erysipelas on the following day. The erysipelas streptococcus has no power of attacking or dissolv- ing sound skin, but may easily penetrate the delicate connective tis- sue which constitutes a new cicatrix. Konig found in nineteen of thirty-six cases of " spontaneous" erysipelas a slight in jury, which could not be recognized in the rest on account of the great swelling of the affected tissues ; and Volkmann declares that scarcely an ex- ception can be found where ' ' idiopathic " erysipelas does not start from a wound, as from a scratched pustule or some such break. Auto-infection with the finger nails is an interesting illustration of this point. A medical student, under the observation of the author, affected with erysipelas of the face, reinfected himself in the leg by- scratching, and quickly succumbed to the double infection. Here, too, it must not be forgotten that light lesions, visible points of pre- vious infection, may be healed to leave no trace in twenty- four hours. The disease spreads for the most part by direct contagion ( i. e. , from bed to bed in a hospital ward), and remains thus confined to closed apartments — hospitals, prisons, ships, etc. In St. Bartholo- mew's it spread by attacking the nearest patient with an open wound. In the Berlin Charite erysipelas was confined, on one occasion, to the various occupants of certain beds directly over a defective privy pipe,, the repair of which put a stop to the disease. Radeliffe discovered and removed a similar cause of erysipelas in Oxford, in 1874, in choked sewer pipes. A still more instructive case occurred in the Middlesex Hospital, where erysipelas was strictly confined to two beds, successive occupants being invariably attacked ; with the re- pair of a flaw in a privy pipe, finally discovered in the adjoining wall, the disease disappeared for a time, to return in the same way after the lapse of ten years. Mindful of former experience, the pipe was again examined and again found defective ; on mending it no new case occurred (Zuelzer). Goodfellow reports a successive attack of every patient in a ward of thirteen beds, the disease going regu- larly down one side and up the other. Erysipelas thus rarely assumes epidemic proportions and seldom spreads over an entire community. Yet the germ may be conveyed by third persons or things, as by clothing, bedding, instruments, utensiTs, and cases of apparently spontaneous origin find explanation in this way. Thus, in a light epidemic at Rostock, Konig observed that the disease was confined to patients operated on in the amphi- theatre, and the cause was finally located in some blood- saturated pillows, the substitution of which by clean pillows ended the cases. A rabbit inoculated with an aqueous infusion of these pillows was. affected with a diffuse dermatitis which lasted twelve days. 76 ERYSIPELAS. Overcrowding in hospitals, as during the existence of other epi- demics or during war, furnishes the conditions which favor the spread of the disease. This was so often the case in our civil war *' that it was frequently deemed desirable to establish i erysipelas wards' for the isolation and better treatment of those affected" (Woodward). Yet in all cases the specific cause must be first intro- duced. Thus, Calmeil relates that the Paris hospitals were crowded with patients affected with erysipelas in 1828 ; Schonlein observed an extensive epidemic in the hospital at Zurich in 1836 ; Gintrac de- scribed a similar occurrence at Bordeaux in 1844, where every inci- sion, cauterization, vesication, or venesection served as the starting point for an attack ; Trousseau remarked upon the coincidence of puerperal- fever in the Paris Maternite in 1858 with grave erysipe- las in the surgical division. In this connection it may be mentioned that Doyen (Rheims) declares that he was not able to discover a streptococcus among the micro-organisms of the vagina, so that it must be always carried to the uterus by hands, instruments, etc. But while pyaemia and gangrene were very frequent, erysipelas was almost unknown during the Crimean war, and Volkmann did not see a single well-marked case in Tratenau and other hospitals in 1866, where about one thousand wounded were quartered. And while the disease was very infrequent in quickly established and necessa- rily badly kept lazarettos in France, it attacked fully two per cent of the wounded in the " well-situated" hospitals of Berlin. The period of incubation is very short — but one or two days as a rule ; exceptionally, according to Heiberg, the temperature rose in the Rostock epidemic in two hours after a surgical incision. One invasion is said to rather predispose to than prevent subsequent at- tacks, though most cases of so-called habitual erysipelas are mere erythemas, simple dermatitis, carbuncles, drug eruptions, etc. Symptoms. — Erysipelas is usually introduced by a chill or series of chills, with malaise, anorexia, nausea, sometimes vomiting, headache, sometimes delirium, scanty urine, hot, dry skin, and fever in varying degrees of intensity. The temperature rises rapidly to 102° to 105° F., to fall in three to five days, or reascend later with each new extension of the disease. The general symptoms are due to the development of a chemical poison, toxine, since the strepto- coccus does not enter the blood. The eruption or local manifestation shows itself most commonly about the face (in twenty-eight of forty-two cases — Hey f elder), on account of its greater exposure. The region of the nose is the most frequent starting point ; nose twelve, ear six, eyelids five, scalp five, etc. And this predilection for the face is observed even though ERYSIPELAS. 17 wounds of the extremities are twice as frequent (Billroth) — a fact which of itself demonstrates outside infection. The eruption appears as a rose-red flash, which rapidly spreads from the part affected like red ink over blotting paper. The skin is swollen, glazed, and (Edematous; pits hence on pressure, and burns as if scorched by fire. If the nose be the starting point, the disease spreads toward the lips, ear, forehead, scalp, nucha, but not downward over the chin. Commencing elsewhere, as at the back of the neck or scalp, it pur- sues a reverse course, but still respects the chin. From the breasts it extends toward the axilla and over the chest, but does not pass down over the xyphoid cartilage. The germ follows the rhombic meshwork of the skin (as indicated by the lines of tension or elonga- tion after a circular punch), along which the lymph vessels course, and meets with obstacles where these lines cross, as at the chin and ensiform cartilage, or where the skin is bound down to bone or subcutaneous tendons. Visible tongue-like or dendritic pro- longations may reveal its progress in this way up to adjoining lymph glands, which show in- vasion by tenderness and swelling ; or wall-like indurations may indicate its advance en masse, erysipelas marginatum. Vesicles, always visible with a lens, and blebs frequently form on the affected surface. Barring exceptional Fr&. si. — Temperature cases (erysipelas fixum), the disease does not ^*^ cial8rr - last longer than four days in one locality, though previously affected regions may be revisited as a result of reinfec- tion. More widely or rapidly advancing cases constitute erysipelas migrans, s. ambulans, s. serpens. Vaccinal erysipelas in a feeble child may thus spread over the whole body in less than a week. The deep discoloration, more especially the great swelling, cede- matous infiltration, of the parts affected, produce deformities quite characteristic of the disease. The eyelids are puffed to complete closure, the nares blocked, the ears bloated, the lips protuberant, the face seems a shapeless mass or repulsive mask like that shown in small-pox. Drops of sticky serum ooze out upon the glazed surface from ruptured blebs, to add to the picture of distress. Infiltration of the scalp gives it a doughy sensation to the touch, lifts it from the cranium, or interferes to such extent with the nutrition of the hair as to cause it to fall — defluvium capillitii — to be restored, how- ever, in all cases with the subsidence of the disease. The back of the neck may present the appearance and give the discomfort of a huge carbuncle. 78 ERYSIPELAS. At this time, during* the height of the disease, there is always more or less delirium, muttering, insomnia, or more frequently somnolence and coma, more rarely mania, especially at night. The tongue is heavily coated, fuliginous ; the spleen is swollen; the bow- els constipated ; the urine scanty, and albuminous from fever ; and complications of various kinds, some of great gravity, are liable to ensue. But just at this time, as a rule about the fourth or fifth day of the disease, when the gravest apprehensions are being entertained, resolution sets in, occasionally with epistaxis or herpes, more rarely with suppuration, with fall of temperature, subsidence of swelling, frequently with desquamation of the skin, and in an incredibly short time there is restitutio ad integrum — i.e., to leave no trace of pre- vious affection. And so, "as if by magic, a hideous monster was metamorphosed into a comely damsel " (Watson). The disease lasts usually three to ten days. Erysipelas is not confined to the outside skin. It may originate in or subsequently invade also the various mucosas, to produce the same changes as in the skin. Gerhardt thinks it questionable that we should regard all internal affections occurring during the course of erysipelas as directly caused by the disease, though he admits the possibility of an intimate connection with pericarditis. Diseases of the mucosae by extension from the skin or from border lines would seem to admit of no other explanation. So also subsequent exten- sion from the mucosa? to the skin, with typical manifestations in the skin, furnish evidence satisfactory to diagnosis. Thus, to quote one case from a now crowded literature, Wells reports an erysipelas fau- cium, characterized by fever, thirst, headache, swollen glands in the neck, pharyngeal oedema and redness, with phlyctenulse, subsequent invasion of the nose, and in forty-eight hours of the face, with typi- cal signs, and final recovery. Pozzi speaks of erysipelas of the nose, ear ducts, external auditory canal, drum cavity, and Eustachian tube. Cordone remarks that hitherto pharyngeal erysipelas has been considered secondary because of the absence of proof of primary af- fection by bacterioscopic examination. This proof he claims to have furnished in four cases of what he calls "unconditional" erysipe- las. In all these cases fluid withdrawn from phlyctenulse in the throat by a sterilized syringe furnished, among other micro-organ- isms, Fehleisen's streptococcus, as demonstrated by subsequent culti- vation and inoculation experiments. The pharynx offers a favorable nidus for erysipelas, he says, because of the richness of its lymph plexus. Thus in the throat erysipelas may simulate diphtheria or scarlet fever, the deeply reddened surface becoming swollen, tense, and oedematous ; in the larynx it may assume the sudden gravity of oedema of the glottis. The vagina is less frequently involved, but ERYSIPELAS. 79 the coincidence of erysipelas with puerperal fever, already noticed, shows involvement also of the uterine mucosa. Complications. — Abscess of the skin, gangrene, bronchitis, pneu- monia ; more rarely, oedema of the glottis ; more frequently, endo- carditis, pericarditis, meningitis ; icterus, dysentery ; more rarely, cnterorrhagia, ulcer of the duodenum, peritonitis; according to Hart- mann certain cases of " spontaneous peritonitis are caused by the •erysipelas coccus " ; nephritis ; Cerne claims to have found the strep- tococcus in the urine ; affections of the joints ; exceptionally paroti- tis, keratitis, amaurosis, panophthalmitis ; paralysis. Diagnosis. — Erysipelas is written upon the surface in its intense redness and stuelling, origin about a wound, characteristic deform- ity, fugacity, and restitutio ad integrum, together with the con- stitutional distress and complications. It is distinguished from erythema by the more tense, glazed, and cedematous condition of the skin, arising about a broken surface, by its more strict locali- zation, blebs, indurated margins, fever, with other signs of toxae- mia which do not belong to erythema. Erythema nodosum, though associated with fever and often with gastric distress, is recognized by its nodosities, especially about the joints. Drug eruptions after the antipyretics, copaiba, etc., have a history, less severe local, and no constitutional signs. Malignant pustule (milzbrand) and malig- nant oedema, rare affections, show characteristic bacilli ; erysipelas, characteristic micrococci. Prognosis. — The prognosis is favorable as a rule, for, as observed by Hippocrates, the disease is more ' ' formidable in appearance than reality." The occurrence of suppuration, which is comparatively rare, and is certainly indicative of mixed infection, does not aggra- vate it greatly. ' ' Verum ac legitimum erysipelas raro terminatur suppuratione, sed magna ex parte insensibili transpiratione seu reso- lutione" (Yidus). Previous debility reduces the rate of recovery, and symptoms on the part of the nervous system are especially threatening. Rapid spread, undue protraction, reinfection, relapses, complications, gravely affect the natural tendency to resolution. Prophylaxis is difficult on account of the extreme tenacity of the streptococcus, which fixes itself to walls, carpets, curtains, bedding, almost ineradicably. Ferraro propagated erysipelas from strepto- cocci kept dried on a silk thread fifty -two days. Walls should be rubbed down with bread; furniture disinfected by long ventilation in the open air ; rooms flushed with fresh air day and night ; floors scrubbed with corrosive sublimate ; bedding, clothing, etc. , subjected to steam heat or destroyed by fire ; patients isolated as much as may be. Attendants should not wear woollen clothes. Above all things, instruments, best wrapped in towels, should be placed in 80 ERYSIPELAS. boiling water for five to ten minutes, and utensils thoroughly scalded out. Treatment. — The treatment of erysipelas is based upon attempts to destroy or limit the extension of the streptococcus, and to support the patient during the progress of the disease. Fehleisen found that thin layers of the streptococcus perished in a one-per-cent solu- tion of carbolic acid in forty-five seconds. Gartner and Plagge de- clare that cocci cultivated in bouillon feel the deleterious influence of a three-per-cent solution of carbolic acid in eight to eleven sec- onds. Hartmann observed all streptococci, wet or dry, perish under five to ten minutes' exposure to undiluted liquor ferri sesquichloridi, which absolutely destroys those on the surface, but only limits or checks the development of those deeper in the tissues. These facts furnished by the bacteriologist give the clue to the scientific treat- ment of the disease, as well as explain the failure of specific treat- ment hitherto. Mild cases require no treatment beyond wet compresses or inunc- tions to relieve the heat and tension of the surface. More severe or rapidly spreading invasions may be attacked by antimycotic agents, at the head of which stand the agents mentioned. External appli- cations are obviously useless. The fact that so many practitioners of the ' ' school of experience " possess specific applications, each dif- ferent from the rest, is patent proof of the inefficiency of all of them. Scientific disproof of such specificness is offered in the report of Polotebrow (1888), of St. Petersburg, who made parallel observa- tions in sixty cases, thirty of which were treated with cold-water compresses alone and thirty with energetic applications of nitrate of silver — 4 : 30 — over the affected surface and two or three fingers' breadth beyond it, without influence on the temperature, nervous symptoms, albuminuria, or other complications, and without appre- ciable difference in the duration or mortality, which was one in each set of cases. Hueter first employed carbolic acid subcutaneously, introducing the agent beyond the limit of invasion. This treat- ment, which is admirably adapted to the trunk or extremities, is impracticable about the face or scalp. Bogusch recommends the subcutaneous injection of resorcin 1.5:30 aqua destillata ; Cattani, the application of the same agent, two- or three-per-cent solution, every two hours, externally by means of a brush or saturated cot- ton, together with its internal administration (4:6) in water, barley water, or red wine. Hucker advises the painting of the surface with cocaine in relief of pain. Hofmokl applies compresses of a three- to five-per-cent solution of carbolic acid, and covers them with some material impervious to water. Lovanz paints the surface repeatedly with a mixture of ichthyol twenty, glycerin and ether ANTHRAX. 81 each ten. Duckworth uses an ointment of equal parts of chalk and melted fat. Barwell applies white lead as quickly and as thickly as possible. The Berlin Charite paints the surface with a concentrated solution of carbonate of lead in glycerin, and covers it all in with cotton. Popoff applies with a brush trichlorphenol, five-per-cent solution, in glycerin. Winiwarter claims to check the spread of ery- sipelas migrans as follows : The affected surface is washed, or, if the extremities, bathed, in a three-per-cent solution of corrosive subli- mate. Next is applied to it, and to two fingers' breadth beyond it, a thick layer of tar, which is now covered in. The covered surface becomes macerated in a few days, and is next redressed with subli- mate water in but one-per-cent solution, which thus checks the fur- ther advance of the disease. Much more radical treatment is prac- tised by Kraske, who makes multiple punctate scarifications and small incisions one centimetre long through the corium, and in places through the whole skin, washes over and rubs into the surface a five-per-cent solution, and covers it all in with compresses saturated with a two-and-one-half-per-cent solution of carbolic acid. A recent remedy, highly lauded, is : R . Iodoformi, Creolini aa gr. xv, Unguenti petrolati 3 ss. Lanolini § iss. M. Apply with a brush. The use of this preparation is said to check fever and stop the spread of the disease after three applications. Wolfler claims to have cut short fifty-eight of sixty cases by strapping the surface with adhesive plaster. The real value of any or all of these remedies remains to be tested by time. They seem at present to show the direction of modern therapy as determined by etiological discovery. Few practitioners will now maintain a specific action for any in- ternal remedy, though none will deny the necessity of sustentation of the patient by alcohol, if necessary, until the disease shall have run its course. The natural tendency of the disease to resolution in the course of a few days makes it difficult to decide whether any ' ' cure " be due to Nature or to art. It is wise to keep the bowels open with calomel and Carlsbad salts, to allay nausea and vomiting with small doses of chloral, gr. ii.-v. in peppermint water. Here, as everywhere, "ubi pus, ibi incisio." ANTHRAX. Anthrax (avOpag, coal) ; carbuncle ; malignant pustule ; splenic 6 82 ANTHRAX. fever; German, Milzbrand ; French, charbon. — An exquisitely acute, often fatal infection, caused by the Bacillus anthracis ; charac- terized by the formation of a boil with a black centre (anthrax), ex- tensive circumjacent infiltration, and subsequent sepsis ; in internal form by rapid toxaemia and the development of metastatic carbun- cles in the skin. History. — Anthrax existed in the most remote antiquity. It is recognized that most of the fatal plagues which chiefly affected ani- mals, and not infrequently men, correspond to the sjunptomatology of anthrax. The plague of murrain with boils and blains, on man ^and beast, mentioned in Genesis, is believed to have been anthrax (Blanc). The Bacillus anthracis (Pollender, 1855) is famous as the first micro-organism discovered as the actual cause of an infectious dis- ease. It is the longest known and best studied of all the micro-organ- isms. Etiology. — The milzbrand ba- cillus is a motionless rod of elon- gated, jointed cells, 0.005 to 0.0125 mm. in length — i.e., two to ten times as long as a red blood cor- puscle— 0.001 to 0.0015 mm. broad. Under proper conditions it forms in the culture soil, but never inside of the body or tissues of the living ani- mal, endogenous spores. Decom- position, the action of the gastric juice, quickly destroy the bacilli, but fail to attack the spores. The ingestion of meat free of spores produces no infection. The inges- tion of meat with spores infects infallibly. In San Domingo (1770) fifteen thousand persons perished in six weeks from eating the bodies of animals dead of the disease. Freezing affects neither the bacilli nor the spores. Anthrax infects chiefly herbivora, next omnivora, least carnivora, man as an omnivorous animal. The disease is therefore not quite so dangerous in man as in some other animals. The Bacillus anthracis is a saprophyte. It goes through with all its phases of development outside, and makes only accidental incursion into, the body of man. Martin succeeded in extracting from cultures certain chemical pro- ducts : first, proto- and deutero-albumose ; second, an alkaloid ; third, small quantities of leucin and tyrosin. Mice injected with the proto- and deutero-albumose were affected with oedema at the place Fig. 82.— Anthrax bacillus, with and without spores, from spleen (Woodhead and Hare). ANTHRAX. 83 of injection, and with a sufficient quantity (0.3 gramme for a mouse weighing 22 grammes) they were killed. Similar symptoms were produced with the alkaloid (0. 1 gramme fatal to a mouse weigh- ing 15 grammes). Hankin also found an albumose which he in- jected in prophylaxis against the disease. Anthrax is peculiarly malignant in small animals. It is so surely and quickly fatal to mice, guinea-pigs, and rabbits as to make their bodies the best phy- siological tests in cases of doubt as to the nature of a micro-organ- ism. Anthrax is usually conveyed to man by contact with a diseased animal or by the ingestion of its flesh as food. Individuals most closely connected with cattle are chiefly affected — butchers, stable boys, shepherds, veterinary physicians, etc. On account of the great tenacity of the spores, people who come in contact at any time with the skins, hairs, bristles, cloths, horns, hoofs — as tanners, brushmakers, upholsterers (horse-hair), wool sorters, rag sorters, glue makers, etc. — may be affected through open wounds in the skin or through in- halation of dust. Since Bollinger demonstrated the bacillus in the stomach of car- nivorous flies, and with Raimbert and Davaine produced the disease by inoculation with the stomach, legs, and feelers of these insects, it must be admitted that malignant pustule may be conveyed by in- sects. It had long been remarked that malignant pustule occurs more especially on the exposed parts of the bod} T — face, hands. Bell, of Brooklyn, found fifty-six of sixty cases on the face, two on the hands, one on the wrist, and one on the forearm. It was evident that the bite of a fly or mosquito had often originated the disease. Extensive epidemics have been caused, as stated, by the ingestion of raw or insufficiently cooked flesh. Animals rarely contract the dis- ease from each other ; they get it from the soil. It has often been observed that certain regions are centres of infection where the dis- ease shows itself year after year. The superficial burial of carcases leads to infection of the soil, which, once produced, is seldom eradi- cated. The disease is spread chiefly in the warm months of summer, when the soil is softer, by grazing upon its surface, and is trans- ported by streams of water which convey infected soil to a distance. Floods may disseminate the disease to places previously free. Stable utensils, fodder, hay from anthrax fields, litter, harness, surgical instruments, have been known to convey the disease. The foetus is not infected as a rule. The placenta, when sound, acts as a filter. Exceptional cases have been accounted for by lesion of the placenta. Immunity is not secured by a single attack.. Symjjtoms. — The disease presents itself in two distinct forms, one as it originates externally, the other internally. The external 84 ANTHRAX. disease is the anthrax, malignant pustule, or charbon, with its le- sions in the skin and subjacent tissues. The internal is the intestinal or thoracic mycosis, which is recognized by the general signs of toxaemia, the nature of which may be, if unsuspected, overlooked. The external disease is confined to individuals ; the internal may as- sume, as stated, endemic and epidemic proportions. The period of incubation varies from one to several days. Symp- toms may show themselves in a few hours after inoculation. They may be delayed as late as four days. A slight itching, prickling. or burning sensation is first perceived on the face or neck at the site of inoculation. Sometimes the patient feels as if he had been just stung by an insect. Very soon appears a papule with a central vesicle, the rupture of which discharges bloody contents, to be con- verted into a dark red-brown or black crust — the anthrax. Smaller vesicles may appear about it. The parent nucleus, as Virchow called the first eruption, rapidly extends ; the skin swells about it, be- comes indurated, livid, and hard. The subcutaneous tissues are ex- tensively infiltrated with serum. The appearance is characterized as a " brawny oedema," which rapidly spreads to involve a mass of tissue, the whole of one arm or of one side of the neck, in the course of a few days. Lymphangitis and swelling of the lymph glands, with. phlebitis, are frequent complications. For the first day or two. there may be no disturbance of the general health, the patient may even continue at work ; but toxic signs set in, as a rule, by the end of the second day, with delirium, diarrhoea, sweating, vomiting, and collapse, and so the patient may die of heart failure in five to eight days. This result, however, is not so frequent as was formerly sup- posed. In the majority of cases the local inflammation begins to abate in the course of a few days. The anthrax sloughs off and the subjacent ulcer closes over by granulation. A sub-variety of this condition was first described by Bollinger as anthrax oedema. In this form the local lesion is absent. The poison seems to be introduced more deeply into the tissues,, and chemical products produce an cedematous state of wide range. This variety is most often noticed in the region of the eyelids. The internal mycosis announces itself more distinctly as an infec- tion. The disease begins suddenly with chill, pain in the head and joints, vomiting, and diarrhoea. The case looks like a poisoning, which it is. Free haemorrhage may occur from the mouth, nose, and kidneys. Nearly always (exceptions by Bonisson) there is an outbreak upon the skin of small, phlegmonous, carbuncular inflam- mations, the so-called metastatic carbuncles. There is usually but little fever. There may be much delirium, convulsions? sometimes opisthotonos. There is often prozcordial anxiety and intense ANTHRAX. 85 dyspnoea. Cyanosis and heart failure usually precede the termina- tion, which may occur in the course of a very few days. Where the disease originates in the chest respiration soon be- comes difficult, though auscultation reveals, as a rule, only the signs of a light bronchitis. Diarrhoea is usually absent. The nervous system may be depressed, or so little affected as to lead patients to decline medical advice, even a few hours before death. The case bears the aspect of a rapidly spreading pneumonia with heart fail- ure. Most of these cases succumb in three to five days. Bell de- clares that they who survive for a week recover. This form of the disease has been observed more especially among the sorters of wool. Most of the fatal cases have been hitherto unrecognized. Bell thinks that many of the cases diagnosticated as pneumonia, bron- chitis, congestion of the lungs, etc., occurring in factories of carpets, blankets, furs, etc., are really cases of thoracic anthrax. It is not improbable that some of the cases ascribed to poisoning by mush- rooms, meat ptomaines, etc., are really cases of intestinal anthrax. Diagnosis. — Anthrax is distinguished by its origin as a red papule with a dark centre — "gran nero" — and its rapid extension with brawny oedema. The black central crust is ab- sent, and any extensive surrounding inflamma- tion is absent, in a common boil or furuncle. There is a furunculosis of the upper lip which is ^ l^*lP more fatal than anthrax (Konig). Carbuncles FlG - 83 -- The anthrax , . , , in ,i ,, bacillus in the blood. show themselves much more trequently on the back of the neck, trunk, and extremities ; anthrax occurs on uncov- ered surfaces. Anthrax spreads from one central point or parent nucleus ; carbuncle results from the coalescence of a number of points. Anthrax oedema, in the absence of a central papule, is dis- tinguished by its sudden appearance, its yellow-greenish hue, and septic symptoms. Erysipelas is more superficial, has no anthrax or parent nucleus, and shows no bacteria in the blood. The diagnosis of intestinal and thoracic anthrax is sometimes reached only by exclusion. The nature of the avocation, the exposure to the cause, is the most common index to the condition. The sud- den occurrence, in the midst of health, of the intense signs of a grave infection — headache, nausea and vomiting, dyspnoea, cyanosis, con- vulsions, free haemorrhages, especially of skin carbuncles —in connec- tion with the history of exposure, should lead to the recognition of the disease. In any case of doubt the diagnosis may be established by the examination of the blood under the microscope, or by a phy- siological test. A rabbit, guinea-pig. or a mouse shows dyspnoea, dilatation of the pupils, and convulsions, with death in the course of 86 ANTHRAX. two or three days after inoculation. The blood of these animals then swarms with bacilli. The prognosis is always grave ; that of malignant pustule de- pends upon the stage of its recognition. The disease can be always eradicated at first. In places where its picture is familiar, and where the disease is attacked at once, the mortality is reduced to five to nine per cent, and even this mortality is ascribed to delay in treatment. Under neglect the mortality may reach fifty to sixty per cent. Intestinal and thoracic anthrax, recognized only after general infection, have always, at least at present, a fatal prognosis. Prophylaxis consists in the proper disposition of the bodies of dead animals by deeper burial or by cremation ; by the avoidance of the use of the hides or other products of these animals ; by the destruction of their discharges, as by fire ; by shutting off affected pasture fields, damming up streams of water, etc. ; by the abundant use of disinfectants — carbolic acid, chloride of lime, corrosive sub- limate — in handling suspected wools, horns, and other products ; and by protective inoculation of cattle and sheep with attenuated cultures or antitoxines — a procedure the value of which is yet sub judice. Treatment. — The successful treatment of anthrax depends upon the energy of the local attack. Deep crucial incisions should be made through the substance of the mass, and the gaping cuts stuffed with carbolic acid fluidified by heat. They should be afterward dressed with the more dilute solution 1 : 10. Individual carbuncles may be excised en masse or excavated with a sharp spoon, where- upon the base must be treated with powerful caustics — carbolic acid as stated, corrosive sublimate, caustic potash, etc. Camera best expresses the principle of treatment with the most successful practice in countries where the condition is most frequently encountered, as •follows : The mass is to be circumscribed by a deep incision and penetrated by numerous crucial incisions. Into the bottom of all these cuts is to be strewn corrosive sublimate itself, in powder, 0.04 to 0.15. The liquefaction of the sublimate produces extensive, thor- oughly penetrating destruction of the entire mass. Where the sur- face is so great as to lead to the fear of poisoning by the sublimate itself, its action may be modified and poisoning prevented by ad- mixture with a proportion of calomel. Weil first anaesthetizes the mass with cocaine, scoops it out, and applies to the wound dressings saturated with a one-per-cent solution of corrosive sublimate. Con- tento injects into, under, and about the mass subcutaneously three- per-cent solutions of carbolic acid. In the (Edematous form the whole infiltrate must be abundantly scarified and cut deep down to the healthy tissue in the same way, and dressed in solutions of iodine and carbolic acid. FOOT AND MOUTH DISEASE. 87 In the cases of general infection metastatic carbuncles are to be treated in the same way, and the patient supported with brandy or subcutaneous injections of ether, camphor, or other analeptic. The therapy of internal anthrax is well-nigh hopeless. Where it is known that poisoned meat has been ingested, the stomach should be immediately washed out, or a powerful emetic administered, fol- lowed by a purgative dose of castor oil. For an internal mycosis it has been recommended to administer carbolic acid in dose of three to five drops three or four times a day. It might be better to saturate the blood with creosote, as in the treatment of the sepsis of tuberculosis ; and with alcohol, as in poisoning by snake bites. Not much hope is to be entertained from either plan. The hope which seemed justified by the experiments of Fodor regarding protection by saturation of the blood with an alkali, has proven futile accord- ing to the subsequent investigations of Chor. Future success must be obtained by means of sozines or antitoxines. Hankin, of Cam- bridge, finds certain defensive proteids in the serum of the blood of certain animals. There is a protective albuminoid, a non-dialyzable globulin insoluble in alcohol and water, in the blood and spleen of a rat, which renders a mouse immune against the most virulent anthrax. Kostjurin and Krainsky reached the conclusion that cer- tain toxines from decomposition, introduced at the proper time into the bodies of rabbits affected with anthrax, totally prevent the de- velopment of the disease. Ogata and Jasuhara claim that the blood of animals, dogs, fowl contains a ferment which, injected subcu- taneously in but one- or two-drop doses, acts as a preventive and curative remedy. These disclosures of much promise have not yet been utilized in the treatment of anthrax in man. FOOT AND MOUTH DISEASE Latin, aphthce {anroo, to fasten) epizooticce ; German, Maul klauenseuche ; French, stomatite aphtheuse; Italian, febb re af. tosa. — A mild, acute infection of the lower animals, especially of cattle, sheep, pigs, less frequently of the goat and horse, much more rarely of fowl, dogs, cats, evidently caused by a peculiar micro- organism not yet exactly defined ; characterized by the formation of vesicles and ulcers in the mucous membrane of the mouth, with the development of eruptions and ulcers in crevices about the feet, some- times about the udder ; communicable to man for the most part through the milk of diseased animals, to appear, with malaise and light fever, as vesicles and ulcers in the mouth, of benign course and short duration. History. — The disease was recognized in animals in antiquity, but was, in the early history of veterinary medicine, evidently con- 88 FOOT AND MOUTH DISEASE. founded with anthrax and actinomycosis. Hertwig (1834) established the contagiousness of the disease by experimenting upon himself and two other medical men. They drank daily for four days a quart of fresh milk from diseased cows. Symptoms of fever, headache, dry- ness and heat in the mouth, and itching in the hands and fingers began in two and lasted for five days, at the end of which time vesicles appeared in the mouth. The disease has now, therefore, a recognized place in human pathology. Though benign in its mani- festation and course, it is nevertheless a serious affection from the fact that so many young animals, sucklings, succumb on account of degradation of the milk. It is stated that in many epizootics ^as many as seventy-five per cent of sucking calves perished. The disease, once developed, is exceedingly persistent. Stables remain infectious for a long time. It is gradually transported along the lines of travel, hence along the course of rivers, and with a general tendency westward, to assume at times very wide range. Thus in the year 1871 seven hundred thousand animals were attacked in England alone, entailing in the same year in France a loss of thirty million francs. In 1869 the disease ranged over nearly all Eu- rope. It makes up for its mildness by its range, and costs a country more than the malignant diseases, anthrax, glanders, and rinder- pest. Etiology. — The infectious principle, evidently a micro-organism, has not yet been distinctly isolated. It is certainly distinctly com- municable by inoculation. Nesswitzky (1891) conveyed it with the contents of vesicles and secretions of ulcers, as well as with milk. Inoculation failed in the experiments of the Berlin Health Office in 30. 3 per cent of cases. Klein, Siegel, and Schottelius isolated micro- organisms, but with no other proof of pathogenesis. The disease shows itself in the lower animals as a mild fever attended with a catarrhal inflammation of the mucosa of the mouth and the formation of vesicles and pustules about the feet. The milk of the affected animal is altered in quantity and quality. It is reduced often as much as one-half in man, assumes a yellowish colostrum-like appearance, and coagulates prematurely. It has a bitter, nauseating taste and deposits a dark-yellow sediment. The disease terminates usually in twelve to fourteen days. Man is usually affected through diseased milk, which retains its infection even when added to coffee or when diluted with normal milk in the proportion of one to ten. Boiling absolutely destroys the poison in the milk and renders it perfectly harmless. It is doubtful if the disease may be conveyed by the meat of diseased animals, but instances of infection have been reported from the ingestion of butter and cheese made from the milk of diseased cows. Infection by FOOT AND MOUTH DISEASE. 89 direct inoculation, as in milking, is not uncommon in those who have the care of diseased animals. The chief interest in connection with foot and mouth disease occurs in relation to aphtha, which is declared to be the expression of the disease in man. It has been observed that aphtha prevails in children coincidently with outbreaks of the foot and mouth disease in cattle. What lends also especial support to this view is the fact that the appearance of the disease is much the same in man as in the animals. Symptoms. — The period of incubation in man ranges from three to five days. The disease may begin with ch ills, or chilly sensations, followed by fever, anorexia, and malaise. Vesicles now appear upon the inner surface of the lips and tongue. Along with the sense of heat and dryness there is difficulty in speaking, chew- ing, and sic all owing. The mucous membrane is very much red- dened and swollen, and saliva floivs abundantly. There is often noticed also at this time a vesicular eruption on the ringers and hands, sometimes in association with intestinal disturbance. The vesicles upon the fingers axe at first small and transparent. They soon increase in size and change in color to show purulent contents, and sometimes closely simulate the eruptions of small-pox. Cases have been reported where the eruption was so extensive as to cover the entire body (Biercher). Holm saw vesicles on the nipple of the breast in a woman who drank daily large quantities of milk from cows affected with the disease. The catarrhal inflammation may assume such proportions as to constitute an extensive stomatitis. Briscoe saw a case in which the tongue was so much swollen as to project more than an inch from the mouth. Projjhylaxis includes proper care of the animal regarding pas- turage and stables. Man is best protected by the ingestion of milk from healthy cows. or. if that be impossible, by the thorough boiling of milk from diseased cows. The diagnosis is usually easy. It may be known that the disease exists at the time in animals. The peculiar coincidence of eruption in the mouth and extremities, sparing the rest of the body, is unlike any other eruptive disease. Thus the mycoses of the mouth are un- attended with affections of the feet, and eczemata, etc., of the feet are unassociated with eruptions of the mouth. The prognosis is favorable. The disease runs a mild course, and terminates, as a rule, in from five to eight days. Extensive affection of the hands, with the difficulty of proper protection, may extend the disease to several weeks. Fatal cases have been reported in very delicate children. 00 GLANDERS. Therapy. — Stomatitis is best treated with weak solutions of borax as mouth washes. Erosions and ulcers should be cauterized with the nitrate of silver, which not only protects an abraded surface from irritating contact, but also by its antimycotic properties directly ad- divsses the cause of the disease. The superficial lesions of the ex- tremities may be best treated by lead washes, diachylon ointment,. light bandages, etc. The fever and general distress of infection may call for mild or repeated doses of salicylates, phenacetin, chloral, or Dover's powder. GLANDERS. Glanders (from gland) ; farcy (from farcio, to stuff); Greek, jaoc- Xi? ; Latin, malleus, maliasmus ; German, Rotz, Wurm ; French, morve, — An infection, acute or chronic, of the horse and allied soli- peds, ass and bastards, communicable by inoculation to many domes- ticated animals (but not to cattle) and to man ; produced by the Bacillus mallei; characterized by the formation of nodules (granulo- mata) and ulcers in the mucous membrane of the nose, with dis- charge of fetid pus, as from glands (whence glanders), and also by deposits in the skin and subcutaneous lymph structures (whence farcy), and subsequent general infection. History. — Apsyrtus, a veterinary surgeon in the army of Con- stantine the Great, is credited with having made the first mention of glanders, under the name malts, a term which included, however, many other maladies. Vegetius also spoke of it, and Aristotle de- scribed it in asses. The disease had in former times a much more intense interest, in that to it, at various periods, wa£ credited the origin of syphilis, tuberculosis, scrofula, diphtheria, and pyaemia. The chief interest of glanders at the present day is in connection with diseases of the horse. Schilling of Berlin, and Muscroft of England, recorded accu- rately studied cases in 1821. Raver published the first monograph in 1837. Virchow contributed exhaustively to the pathology of the disease in 1855-63. Etiology. — The question as to the possibility of spontaneous origin was definitely denied with the discovery by Loffler and Schiitz (1882) of a specific bacillus — the Bacillus mallei — which these observers isolated, cultivated, and inoculated to reproduce the disease in the horse. The bacillus of glanders much resembles in form and size that of tuberculosis and leprosy, though it is shorter and more slender than either. It is immobile ; maintains its virulence desiccated for three months ; is readily colored with alkaline aniline dyes. It forms a characteristic colony on the surface of a potato, as a delicate yellowish,. GLANDERS. 91 transparent coat, like a thin layer of honey, as early as the second day. Acting npon the method of Koch with tuberculin, Kalning, of Dorpat (1891), succeeded in extracting from cultures a product which he proposed to use in prevention and treatment. Most unfor- tunately Kalning fell a victim to the disease ; but his studies were taken up by Preusse of Dantzic, and Pearson of Berlin, who also succeeded in- extracting a dark-yellow, rather opaque, oily fluid of peculiar odor and neutral reaction, which they called mallein. and with which they obtained characteristic reactions in horses affected with the disease. The original seat of the disease in the majority of cases is the nasal mucous membrane, whence it may be disseminated through the bocly, to show itself more especially in the skin. The disease may be always recognized unmistakably by the examination of tissue exsected from the masses in the nose or in the skin. It is not readily recognized in fluid secretions, as it is easily destroyed by other bacteria. Field mice may not be used for the physiological test, as they are so exquisitely susceptible to the bacteria of septicaemia. The guinea-pig is to be preferred, as offering a much more exclusive soil. The disease is disseminated, as stated, through FlG - 84 ~ The bacillus the lymph vessels and also through the blood ves- ° g an ers sels, and is communicated to man either through a broken integu- ment, especially in the nose, during the process of currying or feed- ing, or other contact with diseased horses, especially in slaughtering, skinning, tanning. It is sometimes, but much more rarely, conveyed by the ingestion of infected meat — a mode of infection much more common in animals fed upon horse flesh, as in menageries. The most unsuspected and unavoidable source of infection, fortunately of most rare occurrence, is that which occurs in inhaling into the nose or open mouth the discharges from a horse's nose or mouth, as after the act of sneezing, snorting, coughing, etc. Exceptional cases have been recorded from drinking from the same pail used in water- ing horses, or from the common use of a handkerchief. The bacillus may also be lifted into the air and disseminated in the vicinity of the animal, especially in close apartments, stables, etc., whence it may be. inhaled into the respiratory tract of man. The disease has at- tacked and exterminated an entire family, man, wife, and four chil- dren, from the use of the same dish. Glanders occurs in the great majority of cases among hostlers, coachmen, drivers, stock-farmers, veterinary surgeons, butchers — that is, individuals who come in closest contact with the horse — and is, of course, much more common in the male sex. Bollinger found but six females in one hundred 92 GLANDEES. and twenty cases, and then in the case, of women compelled to sub- stitute men in the care of horses. For the same reason children are almost exempt from the disease. Man is much less susceptible to glanders than the soliped. The period of incubation after inoculation or inspiration varies from three to five days. It may extend to three weeks. Symptoms. — The disease manifests itself at the point of inocula- tion with redness, swelling, and pain, with speedy affection of the neighboring lymphatics. Constitutional signs occur in the course of a few days. They may even precede apparent changes in the wound. Chilly sensations with fever are attended with headache and prostration. Vague rheumatic pains, more especially in the Fig. 85.— Farcy buds in the skin. neighborhood of the joints, with local symptoms in the skin, may more distinctly announce the infection. Where or while tho local symptoms or the cutaneous signs are still absent, the disease simu- lates typhoid fever, for which it has often been mistaken. The character of the disease is, however, soon made manifest by the appearance of hard, red nodules, varying in size from a pea to a walnut, much resembling the eruption of small-pox. These nodules soon show softening of the centre and become converted into pustules, which burst, to give vent to thick, fetid pus. The nodules may increase to such magnitude as to form tumors — the so-called farcy buds — or, in the process of suppuration, constitute abscesses, the rup- ture of which leaves ulcers. These ulcers may destroy tissue to such depth as to expose tendons and bones. The process may extend GLANDERS. 93 rapidly in twenty-four to forty-eight hours, or more slowly, to persist for three or four weeks. It is a fact, to be explained, perhaps, by the difference in the role of the nose in respiration, that while the manifestations in the skin are much less frequent and severe in the horse, symptoms on the part of the nose assuming in this animal so much greater prominence, the converse is true of man. Glanders in the nose is less frequent and severe in man than in the horse. Hauff declares that in more than half the cases in man the nose is not at all affected. Occurring in man, it shows the same symptoms as in the horse. The secretions, which may come only from the affected side, soon become changed, and the discharge from the nose shows the same thick, purulent, fetid matter as in the case of the horse. There may be usually seen at a glance, on inspection, such swelling and redness of the nose and Fig. 86.— Tubercular glanders in the nose. face as at times to simulate erysipelas. Sometimes tubercles may be discovered upon the alse of the nose. As in the horse, the affec- tion of the nose may show itself later in the course of the disease, often in the second or third week. , The mucous membrane of the eye, mouth, fauces, and of the whole respiratory tract may subse- quently become involved. The appearance of the membrane, with the tendency to haemorrhage, fetor oris, and dysphagia, may much resemble scurvy. There may be always observed in these cases the same involvement of the glands. The submaxillary and sublingual glands may suppurate to discharge externally. Affection of the bronchial mucous membrane is evidenced by harassing cough, with the profuse expectoration of the same fetid matter and the subsequent development of dyspnoea. Fever may be entirely absent, or may, in an individual case, assume prominence^ 94 GLANDERS. with a temperature at 106°, and a feeble, irregular pulse like that of pyaemia. The chronic distinguishes itself from the acute form by its less intense manifestations and more protracted course. The affection of the nose, when present, does not vary in any essential from that already described. It is, however, less frequently present in man than in the acute form of the disease. There is the same puru- lent discharge with its excessive fcetor, the same swelling of the whole structure, while the nares are blocked with offensive crusts. Peculiar repulsiveness is added to individual cases in gan- grenous changes which may occur at the root of the nose. The manifestations in the skin are much more common, and upon these the diagnosis is, for the most part, established. Nodular masses may form anywhere over the body, more especially upon the ex- tremities, to discharge sanguineous serum and pus. Sometimes the Fig. 87.— Discharging cicatrices in the nose. affection is more superficial and shows itself in the form of blebs, which may simulate small-pox, chicken-pox, or pemphigus. The various complications of pysemia may subsequently ensue. Arthritis, serous or suppurative inflammations of the various serous membranes, with exudations, suppurating nodules, and masses in the muscles and bones, followed by extensive destruction of muscle and necrosis of bone, with deep erosions in the mucosse and subcu- taneous tissues, are common phenomena of marked cases. These various complications may follow each other rapidly in acute cases. The blood is quickly poisoned and the patient succumbs in the course of a week ; in the more subacute cases, in two to four weeks, with delirium and coma. The disease is much more pro- tracted in chronic cases. It may last for several weeks, months, -even years, and finally cause death by marasmus. There is during .all this time constant liability to the development of the acute form with its more rapidly fatal consequences. GLANDERS. 95 The diagnosis is made to rest upon the nature of the avocation and the possibility of exposure. It is further determined by the two signs which have given names to the disease — to wit, the glanders, which finds its analogue in man in the term ozaena. It is to be remembered, however, that ozsena applies also to fetid discharges from the nose from various other causes, notably from syphilis. The second factor is the farcy, the nodular eruptions, abscesses, and ulcers found in the skin. The disease is recognized in its constitu- tional form by the signs of pyaemia — that is, by the chills, fever, and sweats, hebetude, delirium, and coma, together with the various metastatic depots. Syphilis may be separated in a doubtful case, ex juvantibus, as iodine and mercury have no effect upon glanders. Tuberculosis shows, as a rule, predominating signs on the part of the lungs ; and while it may affect the bones, as in a case of glanders, tuberculosis distinguishes itself by sparing the nose and skin, organs of selection in glanders. Small-pox is more uniform. The pustules of glanders appear in successive crops and rapidly ulcerate (Liveing). Pyaemia usually results from a single centre or depot, which may be recognized or discovered. Cryptogenetic cases may be distinguished at times only by the discovery of the specific micro-organism of glanders. The diagnosis of glanders really rests absolutely upon the re- cognition of the Bacillus mallei. Travers, long before the discovery of the specific micro-organism, established the diagnosis in doubtful cases by inoculation of goats and rabbits with matter discharged from some of the ulcers. Bollinger recognized the disease in the same way by the inoculation of a horse. The inoculated animals showed the special lesions and succumbed in the course of two or three months. Cornil succeeded in inoculating two of fifteen gui- nea-pigs by rubbing cultures into the intact skin of guinea-pigs. Washbourn and Schwartznecker established a diagnosis of human glanders by the isolation of the micro-organism, its cultivation, and the inoculation of animals. Jakowski called attention to the affec- tion of the testicle that occurs in these cases, and Strauss adopted the method of intraperitoneal injection as the quickest means of ab- solutely identifying the disease by implication of this organ. He was led to adopt this method on account of the difficulties attending the inoculation of animals with the products of the disease. Subcu- taneous injections in dogs do not always give definite results, and the inoculation of less susceptible animals — e.g., guinea-pigs — is unsatisfactory because of the length of time before death, twenty- five to thirty days. Field mice and marmots succumb in two to five days, but these animals are often difficult of access. 96 HYDROPHOBIA. After the intraperitoneal injection of the discharges of glanders into the bodies of male guinea-pigs, there is observed first, as a pro- minent lesion, affection of the testicle as early as the second to the third day. The scrotum becomes tense, red, and shining, the epi- dermis desquamates. Suppuration speedily occurs, to perforate the integument, and in the pus is to be found the Bacillus mallei. The animal succumbs somewhere between four and fifteen days. The complication results also under subcutaneous injection, but much later — ten to twelve days. Loffler showed that it was not only the tunica vaginalis but also the parenchyma itself which showed nod- ules of the disease. The tunica vaginalis is covered with granula- tions, and by the third to the fourth day its layers are agglomerated by an exudation of pus rich with bacilli. A means of diagnosis is also offered with the injection of mallem (Preusse), which, as in the case of tuberculin in tuberculosis, produces a peculiar febrile reac- tion in glanders. The prognosis in a case of acute glanders is absolutely unfavor- able. The only possible rescue may result from the speedy destruc- tion and thorough annihilation of the first infection. Nearly all the acute and more than half of the chronic cases succumb to the disease. Prophylaxis. — Animals affected with glanders are to be isolated and killed. According to the report of the Berlin Health Office, 1890, there were reported as affected with glanders thirteen hundred and thirty-seven horses. Eighty died ; ninety -three were killed at the request of their owners ; fifteen hundred and ninety-eight ani- mals were destroyed by the police — in all seventeen hundred and seventy-one horses perished. For those killed by the police there was paid by the State 459,834.08 marks indemnity. The cadaver is to be cremated or buried deep. Litter and fodder are to be likewise burned and stables thoroughly disinfected. All persons who have come in contact with infected horses should be warned of their danger. Treatment. — Local depots are to be treated thoroughly and promptly by the application of the actual cautery, strong carbolic acid, mineral acids, and corrosive sublimate, as in the treatment of anthrax. Chronic cases are to be supported with quinine, arsenic (Gamgee), and alcohol. HYDROPHOBIA. Hydrophobia (vdcop, water, cpofio?, fear) ; Greek, Xvffffa, rage; Latin, rabies ; French, la rage ; German, Wuth, Tollwuth, Hundswuth ; Italian, rabbi a; Swedish, Hundsjuka. — An intensely virulent infection of lower animals — dog, fox, wolf, cat, and skunk — in the order of decreasing frequency, communicable also to any ani- HYDROPHOBIA. 97 mal (herbivora, fowl) and to man ; with the most variable, often the longest known period of incubation : distinguished by melancholia, terror, intense hyperesthesia of the medulla ; evinced as a spasm of the pharynx and larynx excited by attempts to swallow, or the pre- sence or the mere thought of liquids, a subsequent very short stage of paralysis, and almost inevitable death. The name is appropriate as expressing the most prominent symp- tom of the disease in man, but is inappropriate for the lower animals, as precisely this symptom, the fear of water, so obtrusive in man, is in them entirely absent. History. — It is strange that while the disease appears to have been known to the ancient Indians, Egyptians, and Israelites, Hip- pocrates makes no mention of it. Aristotle (322 B.C.) recognized it unmistakably in dogs : Ci Dogs suffer from rabies. This induces a state of madness, and all animals who are then bitten by them are likewise attacked by rabies. v Democritus considered it an inflam- mation of the nerves allied to tetanus. It is mentioned by Virgil, Horace, Ovid, Plutarch. Celsus, who first uses the word, speaks of it as the disease which vdoopcpofiiav Grceci appellant. The thorough elaboration of symptomatology in the lower animals as well as in man is chiefly due to English observers, especially to Youatt. Pasteur has connected his name with hydrophobia for all time, with his studies of prophylaxis — studies which established the nature of the disease as an infection whose symptoms are due to toxines from some as yet undiscovered micro-organism, and which fixed the fact of the first importance that rabies may in no case arise spontaneously,, but always and only from itself. Etiology. — Hydrophobia, like syphilis, is communicated by in- oculation through a broken skin ; and while it may be transmitted by any animal, it is actually communicated to man, in the great majority of cases (ninety per cent), by the bites of rabid dogs. The period of incubation in the dog varies usually from twenty to fifty days. It may vary from six to two hundred and forty days. It is certain that the animal may communicate the disease dur- ing the whole of the period of incubation. Escape may be due to accident. A bite after a recent bite is less dangerous. Saliva may have been wiped off in the first bite or ou the garments. The danger is illustrated by the part of the body bit- ten. In some American statistics quoted by Watson, of seventy-five cases the wound was in the hand forty times, on the face fifteen, in the leg eleven, and the arm nine times. Of four hundred and ninety- five cases collected by Bollinger, fifty-three per cent were bitten on the upper extremities, twenty-two per cent on the head and face, twenty- two per cent on the feet, and three per cent on the body and scrotum. 98 HYDROPHOBIA. The cures of the charlatans by so-called madstones, etc. , often of great virtue in psychical cases, get their reputation from use in cases which have escaped real infection. Incubation. — The period of incubation of hydrophobia covers a point of the most intense and anxious interest. How long after a bite may an individual be considered safe ? This is the point in which hydrophobia differs from all known diseases, in that the period of incubation is so indefinite. In the majority of cases it is unusually long. Thus in sixty per cent the period of incubation va- ries from eighteen to sixty days, but in thirty-four per cent — that is, ^ in a little over one-third of all the cases — the period is longer than two months. Cases are abundantly upon record of outbreak of the disease only after the lapse of three to six months, and there are cases upon authentic record where the only exposure which could have accounted for the disease occurred one or even more than two years before the attack. In a very small ratio of cases (six to eighteen per cent) the period of incubation is short, from three to eighteen days. Sometimes these alleged long periods, as well as cases without apparent cause, find explanation in a more recent in- fection which has been overlooked or forgotten. Variation in the time of outbreak has been distinctly observed in dogs. On one occasion six dogs bitten by one rabid animal showed signs of the disease respectively in twenty-three, fifty-six, sixty-seven, eighty-eight, one hundred and fifty-five, and one hundred and eighty- three days. From almost the first recognition of the disease in man attempts have been made from time to time to deny its existence altogether, and to consider hydrophobia a fright or a form of hysteria or of tet- anus. The fact, however, to say nothing of inoculation experiments in animals, that so many children under the age of five (nine per cent), and so many idiots and imbeciles, in whom the imagination could play no role, have succumbed to the disease, sufficiently dis- proves this view. The symptoms, as will be seen, distinctly differ from tetanus ; and the most that may be said of the hysterical origin is the fact that hysteria may simulate hydrophobia or any other disease. Notwithstanding the searching investigations at the hands of the best observers, especially in connection with the study of prophy- laxis, the cause of hydrophobia remains unknown. The analyses of chemistry have failed to disclose it. No specific micro-organism has been detected in the saliva or other fluid, and no distinct toxine has been eliminated from any of the secretions or tissues of the body. The poison is in all cases fixed, never volatile. It is produced only within the body, never outside of it. It acts in every respect like a chemical poison which is evolved from micro-organisms, but differs HYDROPHOBIA. 99 from all the known poisons by the length of time in which it may remain innocuous in the body. Other secretions than the saliva, as well as the flesh of animals, as a rule fail to convey the disease. Various theories have been proposed to account for the long latency of the disease. The latest assumes that the poison lies latent at the wound, and from it chemical products are occasionally intro- duced into the blood, but are neutralized from time to time by the serum of the healthy blood, by the so-called protective proteids which act as antitoxines or antidotes, until finally they fail, to permit in- toxication. This view has now the best support. It accounts for the escape of so many cases with the simultaneous infection of others. It furnishes an explanation of the fact that the bite of a dog in the stage of incubation may be, but is not always, infectious. It accounts also for the favorable influence even to the prevention of the disease by the destruction of it at its origin. It allies it with other poisons, as in a case of septicemia, where the removal of a local depot may put a stop to a long train of septic signs. Morbid Anatomy. — The only changes which can be said to be at all characteristic are microscopic, and they are, with the rest, some- times entirely absent. The small vessels are dilated, and invested upon their exterior with leucocytes, which invade also the circum- jacent tissues. These changes are most marked in the medulla and the upper part of the spinal cord, as well as in the cerebral cor- tex, whence the symptoms of hydrophobia arise. Gowers observed this condition in seven of nine cases. Emigration or accumulation of leucocytes is at times so great as to fill up the whole space within the lymphatic sheath. These escaped and accumulated cells consti- tute what may be called miliary abscesses. In association with them are observed at times small haemorrhages, seldom large enough to be visible to the naked eye. This perivascular accumulation of leuco- cytes, especially in connection with the vessels of the medulla and cortex, constitutes the most constant and characteristic lesion of hydrophobia. Unfortunately, as stated, this sign, with all the rest, is sometimes entirely absent. Symptoms. — Hydrophobia is divided into three stages : the psy- chical, spasmodic, and paralytic. The disease is exceptionally an- nounced by changes at the seat of the wound, which, as a rule, has long since healed. The wound may open anew or become the seat of pain, itching, numbness, or other paresthesia. Sometimes pain irradiates from it in various directions. Sometimes the first feeling is in the nose or throat — a sneezing, a dryness or rawness, which is con- sidered " a cold." A peculiar state of depression and irritability soon sets in, sometimes suddenly with headache, anorexia, insomnia, anxiety. 100 HYDROPHOBIA. Mental symptoms assume prominence according to the temperament of the individual. A man may deny the fact that he ever was bitten by a dog, while he is unable to divert his mind from the actual occurrence and the terrible consequences which are liable to ensue. The inquiry or suggestion of a thoughtless, meddlesome, or inqui- sitive neighbor will plunge the strongest man into melancholy or mania. The mental distress is, however, always an exaggeration of a state of apprehension, of a sense of impending danger or im- minent death ; and though a man may show, under the stress of this suffering, signs of insanity, there is no time when he may not be ^recalled to himself by a right address. A patient affected with the first stage of hydrophobia presents a pitiful picture. He sits quiet, apparently listless, his whole mind intensely concentrated upon the one thought from which no appeal or address may really divert him. It is only in the very first hours of the attack that he may find relief in walking about or in change of scene. He soon becomes exhausted, and sits with an expression of intense anxiety to which he makes total surrender. At the same time the special senses are keenly alert, so that a flare of light, a draught of air, a noise, may produce intense excitement. The very first day shows the characteristic sign of the disease — the fear of water. The patient suffers with thirst, but is unable to allay it. He may make the attempt, may succeed at first in swallowing a mouthful or two, but soon abandons it, either on account of the intense suffering which ensues, or from the fear of its certain following. An unmistakable sign of the disease is the occurrence of burning, more especially a sense of tightness or constriction, of the larynx. The fear of water is the fear of exciting spasm of the larynx, and the reflex excitability of the larynx be- comes so intense that spasm is later precipitated by the sight, the sound, or the mere thought of water, even by the mere sight or touch of a smooth or cold surface. A coachman under Watson's observation had to desist from sponging himself, according to his habit, with cold water, though he said he " could not think how he could be so silly." Frequent sighing is a common sign at the in- ception of the disease. The first stage usually lasts about twenty-four hours, when the second stage, the spasmodic or true hydrophobic stage, sets in. This stage is characterized by an exaggeration or an intensification of the spasmodic contraction of the larynx. Every attempt to swallow is attended with frightful anxiety. The contraction is so powerful as to lead to dyspnoea with maniacal excitement. The patient may strike about in every direction, roll his head from side to side, while the mouth opens and closes convulsively, sometimes with snapping sounds, whereby wounds are occasionally inflicted HYDROPHOBIA. 101 upon ministering hands ; and the disease has actually been conveyed in this way. These convulsive seizures gave rise to the stories that hydrophobic patients bite and snap like dogs, and led, through the fear which they excited, to the cowardly assassination of patients by shooting them down — a practice still in vogue on the confines of Austria — or by smothering them between feather beds. The parox- 3 T sms seem all the more dreadful because they are attended with the escape of glutinous, foaming saliva, which is sometimes ejected with great force in every direction. Inspiration is also attended with gaping and sighing and various sounds, sometimes simulating the bark and howl of dogs. These things occur in paroxysms, in the interval of which the mind is clear, though sometimes, in highly nervous temperaments, it may be excited to show more persistent hallucination. The pulse is quickened and rendered irregular, but with all the struggle there is, as a rule, but little elevation of tem- perature. The employment of any forcible measures of restraint aggravates the explosion. The second stage lasts, as a rule, from one to three days, rarely as long as four days. The patient now becomes gradually exhausted. Paroxysms occur, but they are less intense. The extreme anxiety of mind is diminished; there are intervals of nearly complete tranquil- lity. It is plain to see, however, that while the breathing is easier and the explosions less severe — there may be even ability to swallow — the patient becomes more and more prostrated and reduced. The strong man is broken. The heart's action is weak, the pulse flutters, the surface is covered with a cold sweat. The movements of the body are so much enfeebled as to present the appearance of para- lysis ; hence this third stage has been characterized as the stadium paralyticiim. Death, which may occur suddenly in a convulsion or from asphyxia, usually does occur quietly from failure of the heart. Hydrophobia is an exquisitely acute infection. However long the period of incubation, the whole duration of the disease proper is measured in a few days. Eighty -two per cent of cases perish in from two to four days. Individual cases may succumb in two or may last as long as five or six days. The diagnosis is generally easy, and rests chiefly upon the height- ened reflex of the medulla, as manifested in spasm of the muscles of deglutition and respiration. The disease is differentiated from tetanus by its much longer period of incubation. Tetanus occurs in from three to ten days after the wound or injury. Tetanus usually begins with trismus, and is often attended with opisthotonos. It lacks the laryngeal symptoms and spasms of hydrophobia. It lacks also the psychical exaltation 102 HYDROPHOBIA. and mental anguish of hydrophobia. Tetanus may also be distin- guished by its special micro-organism. The disease is often distinguished with great difficulty from the imaginary condition known as lyssophobia, or fear of hydrophobia. These cases have a common origin, though in the one case the wound comes from a non-affected animal. It might be imagined that lysso- phobia occurred more frequently in nervous subjects or in women. This is not the case. The strongest men have suffered, and not infrequently actually succumbed to fright or fear of hydrophobia. Some of these cases have been rescued by knowledge of the fact that the animal was not rabid ; hence the advisability, when possible, of ^secluding the animal, that the existence or course of its disease may be observed. The fact that the animal recovers at all almost necessarily excludes hydrophobia. Abundant cases are recorded where informa- tion of the recovery of the animal, or the sight of the animal itself, has allayed the most intense nervous symptoms. The prognosis is fatal. It is commonly said that the physician that cures is death. Bollinger goes so far as to say that the cases of alleged recovery may be invariably found to be due to some other disease, or to the fact that the animal was not rabid. Yet it must be admitted that dogs have recovered from the disease. Law mentions eight such cases, two of which were attested by successful inoculation of other animals. The possibility of spontaneous recovery may there- fore be entertained in man. Wounds on the face are, as stated, al- ways the most serious. Bouley declares that ninety per cent of these cases are followed by hydrophobia, whereas the mortality from wounds of the hands is sixty-three per cent, of the lower extremities twenty-eight, and of the upper extremities twenty per cent. Many cases are certainly rescued by prompt treatment. Bollinger quotes in proof the following statistics in France : Of two hundred human beings bitten by rabid animals, one hundred and thirty-four were cau- terized. Of these, ninety-two (that is, sixty-nine per cent) remained healthy, while forty -two (that is, thirty-one per cent) died of hydro- phobia. Of those not cauterized, eighty- three per cent succumbed to the disease. In one case sixteen persons and one ass were bitten by the same animal. The human beings were cauterized and rescued without exception ; the ass, which received no treatment, died of the disease. The only true prophylaxis is the muzzle, which renders all other prophylaxis superfluous. But for various reasons, including a kind of sentimentality, the process of muzzling had never been rigidly en- forced outside of a military country like Prussia. The disease, which was formerly common in Prussia, was actually extinguished, as stated, for nine years by the rigid enforcement of universal muzzling. Hoi- HYDROPHOBIA. 103 land secured nearly the same exemption in the same way. The num- ber of dogs may be limited by being subject to higher taxation. Every dog should have a known master. Suspected dogs must be carefully confined, and for as long a period as six months. Dogs im- ported from countries of lax laws in this regard should be quaran- tined for six months. Actually rabid dogs or other animals that need not be preserved to determine the condition of human beings or other animals attacked, should be killed at once. Filing the teeth, or attachment of blocks of wood about the neck, confinement by chains, attempted prophylaxis by injection of virus, are all means too unreliable for practice. Treatment consists in the destruction or elimination of the poison in the wound. Absorption should be first prevented where practi- cable, as on the extremities, by a ligature above the wound. A piece of cord or handkerchief should be firmly twisted about the limb with a piece of wood. Where it may be done, the patient should with- draw the poison from the wound by suction. With proper precau- tions this act may be substituted by another person. The act of suction is, however, dangerous in cases of carious teeth, or wounds in the gum, cheek, or other parts of the mouth. The operation may be done, nevertheless, if the individual take the precaution to rinse the mouth thoroughly, after every suction, with carbolic acid. Hertwig found that the virus of hydrophobia applied to the mucous mem- brane of the mouth and digestive tract was entirely innocuous. This process, which has been resorted to from the most ancient times, has never yet proven infectious. In the first decades of the present cen- tury, in Lyons, certain women — Hundsdugnerinnen — pursued this business as an avocation. They received ten francs for the first, and five for each succeeding suck. On the surface of the trunk and some parts of the face the poison may be exhausted by cups. Immedi- ately after suction the wound should be cauterized. Youatt relied entirely upon such a superficial caustic as the nitrate of silver. As he was himself bitten seven times, and operated on four hundred persons, only one of whom died, and that one, as he declared, from fright, this caustic may be considered sufficiently strong if applied immediately. Caustic potash burns deeper. The actual cautery, as from a poker, a nail, the galvano-cautery, brought to a white heat, would certainly destroy the poison more effectually. Where wounds are very extensive or numerous the effect may be best accomplished with stronger solutions, 1 : 500 or 1 : 1000, of corrosive sublimate. Extensive laceration of extremities may require amputation. Psychical treatment is of supreme importance. Romberg first advised the necessity, on the part of the attendants and friends, " to preserve a calm demeanor, to avoid all allusion to the previous in- 104: HYDROPHOBIA. jury, and to appear cheerful." To secure diversion without effort or remark is an essential factor in the relief of suffering, at least. The intense reflex excitability of the medulla is best met by seclusion in a quiet and rather dark room. The exhibition of cases as curiosi- ties, or as objects of morbid sympathy, is a cruelty, if not a crime. Frequent warm baths, where at all permissible, as at the very start, tend to allay excitability and spasm. Very soon, however, resort must be had to anodynes and ansesthetics. Violent cases may require the use of chloroform. The same object may be at first obtained with chloral. The various remedies recommended as specifics — curare, calabar bean, pilocarpine —have proven useless, except in al- laying spasms. The use of animal poisons has proven equally futile. Watson speaks of cases treated with the virus of snake bites. One man was bitten by nine vipers without effect. Opium is the best shield. Sooner or later resort must be had to morphia in the later course of the disease, preferably subcutaneously, with a view at least to secure euthanasia. With this history hitherto, it may be appreciated with what accla- mation was hailed the claim by Pasteur of the discovery of a means of preventing the disease by the use of attenuated virus. It had been always known that the disease expends its main force upon the medulla. Whatever lesions are encountered in the disease are seen here. So soon as Pasteur had determined that the virus of hydrophobia- comes to be located in the central nervous system, especially in the spinal cord, he began his experiments with this substance to secure attenuated matter. He found that a continued inoculation of the virus from rabbit to rabbit increased its virulence to such degree that after about twenty-five generations he got a virus which showed its- effect after an incubation of but eight days. In twenty -five genera- tions further the period of incubation was limited to seven days. This virus was taken as a so-called virus fixe, as a basis substance for protective inoculation. Pasteur discovered that desiccation of the medulla from such an animal in sterilized glass vessels in which had been put pieces of caustic potash brought about a gradual reduction of virulence. The medulla became less and less poisonous. The drying process was continued, until, after two weeks' desiccation, it was entirely innocuous. Injections were now made with an emul- sion of the non- virulent medulla, and were followed up with emul- sions of medullas of increasing violence up to those which had been dried but one or two days. Dogs so treated were immune to infection with fresh hydrophobic matter. In the treatment of the hydrophobia of man, Pasteur began with weaker preparations — to wit, with the medulla. of the rabbit after TETANUS. 105 fourteen days' desiccation, and increased on the following days up to that of the fifth day, whereby immunity or protection was secured. The attempt to use stronger preparations in a shorter time, in pro- tection against the more dangerous and extensive laceration of Avolf bites, had to be discontinued. This treatment has been used now in thousands of cases ; and while it cannot be said to have furnished perfect results, as a number of cases thus treated have nevertheless succumbed to the disease, it must be admitted that the majority of cases thus treated have been rescued from the horrors of hydro- phobia. The statistics of the Pasteur Institute from 1886 to 1891 show a continued decrease of deaths from 0.91 per cent in 1886 to 0.25 per cent in 1891. In 1891 as many as 1,464 patients passed under treat- ment. These results, brilliant as they are, are eclipsed by the report of Tizzoni and Centanni, who make the extraordinary claim to be able not only to confer immunity, but to actually cure hydrophobia, even after the disease has developed, by the injection of the blood serum of animals rendered immune to the disease. The immunity is conferred by the inoculation of an emulsion of spinal cords (rabbits) attenuated by partial digestion in artificial gastric juice (peptones). Poppi finds that the matter used by Pasteur may be further attenu- ated, by dilution and heat, to act not only like a veritable vaccine in protection against the disease, but also to cure it. These claims have not yet been conclusively established. TETANUS. Tetanus (reravos, tsivoj, to stretch) ; trismus, lockjaw, opistho- tonos {pniade, backward, teivgq, to stretch) ; German, Wundstarr- krampf. — A grave, often exquisitely acute infection, caused by the tetanus bacillus, introduced through a wound or some break of the sur- face ; characterized by excessively heightened reflex under the action of toxines which induce spasmodic contraction of the voluntary mus- cles, first and especially, of the jaw (trismus, lockjaw), face, and neck, and extensors of the spine (opisthotonos); of short duration, often of rapidly fatal termination. Among the larger animals the horse, sheep, and goat are especially liable to the disease. History. — The clinical features of tetanus are so coarse and ob- trusive as to have been remarked in the most ancient times. Some of the finest descriptions of Aretseus were based upon observations of tetanus. " In all the varieties," he says, "there is pain and ten- sion of the tendons and spine, and of the muscles connected with the jaws and cheek, so that the jaws could not easily be separated, even with levers or a wedge. " Hippocrates devoted a whole section to its treatment, and certainly appreciated the gravity of the disease. 106 TETANUS. " Such persons/ 7 he says, " as are seized with tetanus die within four days, or if they pass these they recover/ 7 Most of the contributions of later times have been presented by the surgeons, Laurent, Larrey, etc. Curling wrote his famous " Treatise on Tetanus 77 (Jacksonian prize essay) in 1834; Rose (E.) made the most valuable clinical contribution of modern times to the " Hand- buch der allgemeinen und speciellen Chirurgie 77 (Pitha und Billroth, Bd. i., Abtheil. A, 1870). Mcolaier discovered the bacillus of tetanus in the soil in 1885. Rosenbach demonstrated it in man in 1886. Ga- gliardi reported the first cure of tetanus in man by the subcutaneous injection of the antitoxine of Tizzoni-Centanni in 1892. , Etiology. — Tetanus may occur in consequence of any kind of wound, but does occur much more frequently after contused wounds with penetration of foreign bodies. It is, therefore, frequent after gunshot wounds, and is especially frequent in wounds of the extremi- ties. Wounds of nerves are also attended with special liability. Tet- anus may follow a lesion as trivial as the extraction of a tooth, a vene- section, the sting of an insect, a simple scratch of the surface, the application of a blister, a slight wound of the foot, as from a nail in a shoe. It occurs not infrequently in the new-born from lesions of the umbilical cord, and has been repeatedly observed after a wound of the cervix uteri, as after parturition. The intrusion of a splinter of wood, the lodgment of a fish bone in the throat, have broken the surface sufficiently to introduce or give entrance to the cause of the disease ; and as the cause comes from without, tetanus occurs, in the great majority of cases, in wounds of the extremities. Curling found one hundred and eleven of one hundred and twenty-eight cases on the extremities, and Thamhaym, in three hundred and ninety-five cases, found the locality of the injury in the hand and finger one hundred and nineteen times. Tetanus is a rare disease. Rose states that the mortality of teta- nus in Berlin was but 0.04 per cent, and this included two hundred and sixty-six cases in new-born infants. The disease is most frequent in hot countries. Aside from attack of the new-born, the period of greatest liability is between ten and thirty. The tetanus bacillus is a delicate rod, a little longer than the bacillus of mouse septicaemia. It occurs in irregular masses in the affected tissue, and is recognized by the characteristic development of its spores. One end of the bacillus swells to show an oval, sharply defined, shining spore, and present the appearance of clock- bell strikers, drumsticks, or, better, pins. This spore formation oc- curs in great abundance in the body of the animal, as well as in artificial cultures. The bacilli are easily colored with methyl blue TETANUS. 107 .and f uchsin. Artificial culture is difficult. The bacillus is strictly, i.e., an obligate anaerobe, so that in artificial culture particles of infected matter must be introduced into the deeper layers of blood serum to secure growth. The culture is so commonly contaminated as to require often subsequent separation to obtain it pure. Brieger (1887) obtained from sterilized cultures of the tetanus bacillus a toxine, which in mice, in the smallest doses, produced "the typical symptoms of trismus and tetanus, with fatal termination. Besides this body, Brieger eliminated various toxalbumins with spe- cific properties. The bacilli and spores of tetanus are so widely disseminated in ■soil and dust as to be almost ubiquitous. They abound most on the surface of inhabited soil, and are not entirely absent in uncon- taminated virgin soil. The rub- bish and dust of streets and houses -are soils of predilection. The wide dissemination of the parasite accounts for the cases of apparent ►spontaneous or idiopathic teta- nus, while the fact that the free ►access of oxygen prevents its growth furnishes explanation of the comparative rarity of the dis- ease and the greater liability of penetrating wounds. The period of incubation varies from one to two weeks. Symptoms. — The disease be- gins, as a rule, with spasm of the muscles of mastication. Contraction of the masseters locks the jaws, to produce the condition known as trismus, lockjaw. Con- traction of the muscles of the neck occurs at the same time, or may precede the contraction of the jaws. Rose declares that the contrac- tion of the masseters may be felt by the insertion of the finger within the mouth, and that the stiffness of the muscles of the back of the neck is best recognized, as in cerebro-spinal meningitis, by attempts to lift the body by the head. The affection of the muscles of the face soon produces a peculiar physiognomy. The lips are usually stretched over the closed teeth, to produce the characteristic smile, the risus sardonicus,so graphically described by Hippocrates. Fagge speaks of the case of a girl who was reprimanded by her mother on account of a singular grinning expression of the face, over which she had, of course, no control. This alteration of the physiognomy gives to .the patient the appearance of age. Farr says a man aged Fig. 88.— Bacillus of tetanus. 108 TETANUS.- twenty-six was taken fox* sixty. The disease begins usually mildly,. and increases gradually and progressively. There is in association with the stiffness of the neck or diminished mobility of the jaw some difficulty of deglutition. The muscles are affected from above downward. The spasm extends to involve the muscles of the back. Implica- tion of the groups of great muscles in the spine soon distorts the body. The whole trunk is stiffened like a statue (orthotonos), or is more frequently arched, with its convexity upward, so that the body may rest upon the back of the head and the heels — opisthotonos. The forearms and hands are spared for a long time. Motion, either active or passive, is soon inhibited or lost altogether under the board- like indurations of the muscles. During these states of rigidity convulsive attacks occur with shocks like strokes of lightning. They show themselves in consequence of effort, even of involuntary effort, or as the result of any outside irritation, and express the in- tense reflex excitability of the spinal cord. In the interval the body assumes the position of rigidity from which it has been distorted by the violence of the spasm. The suffering of the patient at this time is indescribable. The spasms are attended with excruciating pain. The mind is perfectly clear, but is weak from loss of sleep and anx- iety. The patient may not satisfy either hunger or thirst, on account of locking of the jaws. The opisthotonos prevents a proper decubi- tus. Individual muscles, especially the recti abdominis, have actu- ally ruptured under the powerful contraction, to discharge masses of blood at their divided ends. Difficulty of breathing, cyanosis, a sense of distress and danger, with lancinating pains at the bottom of the chest, indicate the spasmodic contraction of the diaphragm. Fever may be entirely absent. There is generally some elevation of temperature, which is liable to sudden exaggeration, often without discoverable cause, probably due to the influence of the nervous sys- tem. Extreme elevations of temperature to 110° or 112° are pre-ago- nal. Sometimes there is an elevation of temperature post mortem. The skin is usually covered with sweat — a point often of diagnostic value. The bowels are constipated. There is often suppression and more frequently retention of urine. The diagnosis largely rests upon the early appearance of trismus. Lockjaw from sore throat, mumps, synovitis, rheumatism at the temporo-maxillary articulation, should be easily distinguished by the most superficial examination. The feel of the rigid masseters inside the mouth, and the associate stiffness at the back of the neck, speedily dissipate doubts. Hysteria and hystero-epilepsy may show the typi- cal opisthotonos of tetanus, but hysteria is, as a rule, unattended with trismus ; and when trismus is simulated by the fixation of the TETANUS. 109 jaws, hysteria is recognized by the fact that the intervals of attack are irregular and always entirely free from spasm or pain. The regular invasion of tetanus from above downward, first of the muscles of the face and neck, later of the trunk, distinguishes the disease from the spasmodic contractions of spastic myelitis. Cerebro- spinal and basilar meningitis, which have, in common with tetanus, stiffness of the neck and opisthotonos, almost never show trismus. They have also a different origin and history — i.e., epidemic, tubercu- lous — with associated symptoms, vomiting, headache, hyperesthesia, herpes, etc. , not seen in tetanus. Tetany is distinguished by its typical spasms of days' and some- times weeks' duration, and absolute intermissions ; by the peculiar •contraction or position of the hand, which may be called out by long- pressure upon the nerves or arteries of the arm — the so-called Trous- seau phenomenon ; by the frequent laryngo-spasm ; and by the in- creased mechanical and galvanic excitability of the motor nerves. Hydrophobia, which has. in common with tetanus, spasm of the muscles of deglutition, is distinguished by the much shorter period of incubation, by the trismus and opisthotonos of tetanus, and by the psychical exaltation and anxiety of hydrophobia. By far the most important question in differential diagnosis concerns the recognition of poisoning by strychnia, which is most closely simulated by the effects of the toxines of tetanus. This diagnosis rests upon the following points : 1. The history of origin, where it may be obtained. 2. The existence of a wound. 3. The period of incubation. Signs of strychnia poison supervene at once. Tetanus begins with trismus and gradually descends, sparing, as a rule, except in children, the arms and hands ; strychnia often shows its first signs in irritation of the stomach and in the affection of the muscles, seizes by preference upon the extremities. In tetanus there is persistent rigidity; in strychnia poisoning there are intervals of absolute relaxation. Thus, in the interval between the paroxysms the mouth remains closed in tetanus, but may be freely opened in strychnia. The reflex spasms of tetanus occur later in the course of the disease and increase in intensity, while those of strychnia occur at once, intense from the start. Strychnia poisoning is quickly terminated by death or recovery. Tetanus may be protracted into days and weeks. Golding-Bird reported the case of a boy affected with tetanus, with spasms for fifty-one days, with subsequent per- sistent rigidity, and death on the one hundred and seventh day. Eiselsberg establishes, as a difference between tetanus and other wound infections, the fact that in tetanus local wound reactions are entirely absent. So-called cases of rheumatic tetanus are, therefore, really of traumatic origin. 110 TETANUS. The prognosis is exceedingly grave. Death may occur in any attack of convulsions. The heart has actually, under observation suddenly ceased to beat. Death occurs, as a rule, before the end of the first week, so that, as Hippocrates said, "patients die within four days, or if they pass these they recover." In exceptional cases, however, the fatal termination may not occur for three weeks. The disease rarely lasts longer in childhood than two or three days. The prognosis is so grave in the new-born that, as Bauer declares, the occasional cases of recovery have been looked upon as being probably errors in diagnosis. According to Bichter six hundred and thirty- one of seven hundred and seventeen military cases — i. e. , eighty-eight per cent — were fatal. According to Rose sixty- three per cent of all cases die within the first five, and eighty-eight per cent within the first ten days. The re- lief of the later periods is probably to be explained by elimination of the toxines. Rigidity may persist for some time, even for months, after recovery. The ability to sleep is always a favorable sign. Prophylaxis. — In prevention of tetanus it is to be emphasized that the minutest wounds soiled with earth, dust, or foreign bodies, as splinters, are to be scrupulously cleaned and disinfected. Patients themselves are to be isolated from other surgical cases. In prophylaxis of the new-born it must be observed that the wound at the navel is attended with the utmost care. The aseptic treatment already recommended by various authors meets thus with scientific justification. For all the investigations concerning the origin of the tetanus bacillus- demonstrate that it has an unusually wide ectogonous dissemination. Unclean hands, the use of ban- dages not sufficiently aseptic, and the raising of dust in the cleaning of the puerperal room, sufficed, in the observations of Beumer, to convey the infecting agent. Treatment. — As in hydrophobia or other disease characterized by excessive hypersesthesia of nerve centres, the patient should be kept perfectly quiet. He should be put in a dark room and isolated from curiosity or officious or meddlesome ministration. The most absolute silence should be enjoined, on the part of the patient as well as the attendants. On account of the locked jaw the food should be fluid, but should be as nutritious as possible. Milk, soft-boiled egg diluted with hot water, nutrient soups, stimulants, wine, whiskey, brandy, should be regularly administered. Where the act of deglu- tition excites spasm, the patient may be anaesthetized and, according to the suggestion of Rose, fed through a tube, which may be, as in the case of insane or refractory patients, inserted through the nose. Foreign bodies should certainly be immediately extracted, irritated nerve trunks excised. Angry wounds, "festering sores," may be TETANUS. 1] 1 treated with the powerful antimycotics, carbolic acid, corrosive sublimate, or with the actual cautery. More extensive exsections, more especially amputations, are surgical barbarities of the past. Spasmodic contractions are best relieved by the administration of anodynes. Opium, on account of its associate discomfort and distress, is better substituted in our day by chloral. A large dose — one drachm at first — may be followed by smaller doses, fifteen to thirty grains, every hour or two, or as often as necessary to subdue spasm. Calabar bean and curare have been administered with success in individual cases, sometimes of questionable diagnosis ; but these remedies have failed, as a rule, to secure other than temporary relief. Bacelli recommended the injection of one centigramme of car- bolic acid every hour or two until the spasms entirely ceased. Caliari claims to have cured a case in this way. The hope of successful treatment lies in the use of the antitoxines derived from the blood serum of animals — dogs — rendered immune to the disease, or from the bodies of the bacteria themselves. Tarufri has already recorded a sixth case rescued in this way. The treatment consists in the injection of the tetanus antitoxine obtained from the blood of a dog rendered immune to the disease. Twenty-five centigrammes are injected twice a day. Such improve- ment occurs in the course of a week as to render the further use of the remedy unnecessary, and the treatment is usually concluded with the hydrate of chloral. Unfortunately some of the best observers do not confirm these conclusions. Kitasato was not able to get immunity by tolerance, nor by the use of filtrates attenuated by heat. Rabbits were ren- dered immune in forty per cent of cases with the trichloride of iodine, but the immunity was lost in the course of two months. Im- munity is conferred upon mice by the injection of the serum of im- munized rabbits, but this immunity is lost in forty to fifty days. The fowl is by nature immune to tetanus, but the blood of the fowl does not confer immunity upon other animals. By the second method Ehrlich. Brieger. and Wassermann utilize the antitoxines developed by the bodies of the bacteria themselves, after the manner of Koch with tuberculin. These antitoxines or protective bodies are to be obtained in the milk of parturient animals previously rendered immune in pregnancy by inoculation of an attenuated culture which is gradually increased in virulence. The protective principle remains in the whey after coagulation and sepa- ration of the casein, so that it may be preserved indefinitely. Some of the most sensitive of the lower animals — mice, goats, etc. — have already been protected in this way, but up to the time of the pre- 112 WHOOPING COUGH. sent writing the accounts published of work with man have not been satisfactory. WHOOPING COUGH. Pertussis (per, intensive, tussis, cough) ; tussis convulsiva ; Ger- man, Keuchhusten ; French, coqueluche [used also for influenza] (from coqueluchon, a cape worn by patients). — An acute infection of childhood, distinguished by paroxysms of cough in rapid series, threatening suffocation, terminated by a long-drawn, audible (whoop) inspiration. The name is derived from the fact that the cough is distinguished by a prolonged, forcible, and audible inspiration through a spasmod- ically contracted glottis. But many cases of whooping cough are without this characteristic sound, and, where different stages of the affection may be recognized, the sound is absent during the whole of the first and most of the last stage. The cough consists of a series of short, sharp explosions, spasmodic in their character ; a series of expiratory efforts without stop to catch the breath, until finally, after the lapse of from fifteen to sixty seconds, at the point of exhaustion occurs this prolonged, audible inspiration. It is the series of explo- sive coughs in quick and uninterrupted sequence, the short, sudden cough, the staccato cough, which marks whooping cough. History. — The origin and home of whooping cough are involved in obscurity. According to Mason Good the disease was known to the Greeks ; but their descriptions, as well as those of subsequent writers, do not distinguish it, strange to say, from other spasmodic or catarrhal affections. All authors agree that the disease was cer- tainly definitely described by Baillou (Paris, 1578), who spoke of it as a well-known malady. Etiology. — Whooping cough is an infectious disease, because it is •contagious and prevails as an endemic and epidemic ; because, also, of the absolute immunity which one attack confers. Rare as are second attacks of scarlet fever, measles, or small-pox, still more rare are second attacks of whooping cough. With the other infections it attacks preferably the age of childhood. Facts which have been taken to militate against the views of its infectious nature are ab- sence of fever and indefiniteness of duration. Facts which refute the idea that pertussis is a neurosis are, first, origin and dissemina- tion by contagion ; second, appearance as an epidemic ; third, im- munity conferred by single attack. Neuroses belong to individuals and not to numbers. They show no relation to others and have con- stant tendency to recur. Proof of contagion is furnished by the at- tack of wet-nurses and nurses generally, instances of which are no- ticed in every epidemic. WHOOPING COUGH. 113 The period of preference as regards age is from six months to six years. Sucklings, because of natural immunity, are rarely attacked. Susceptibility diminishes at six and is nearly annulled at ten j'ears. Yet cases are on record where the disease has occurred in infancy and advanced life. From some inexplicable reason the female sex suffers most, in the proportion, according to nearly all authors, of five to four. The disease is not only more frequent but also more severe in girls. Measles, pregnancy, and the puerperium predispose to pertussis. The contagion is conveyed directly. The contagious principle exists in the sputum, hardly possibly in expired air which contains no sputum. It is a contagium halituo- sum. The great botanist Linnaeus, nearly two centuries ago, ex- pressed the belief that whooping cough was due to a contagium ani- matum, which he thought would be found to be the eggs of insects. The principle is thoroughly accepted in our day. Afanassieff succeeded -in isolating from the sputum of whoop- ing-cough patients a short, thick bacillus, which he cultivated upon beef peptone and agar. The bacillus differs in important particulars from forms hitherto described, and gives rise, when introduced into the trachea or lungs of dogs and rabbits, to symptoms simulating whooping cough and to lobular pneumonia. Ssemtchenko, after considerable experimentation, reached the conclusion that the bacillus of Afanassieff is specific. It may be found in the sputum as early as the fourth day of the disease. It multiplies in the body, and as it increases, the disease diminishes in severity. It disappears with the resolution of the disease, or when the paroxysms are reduced to two to four daily. In the presence of complications, especially catarrhal pneumonia, it increases in the sputum. Thus this bacillus is of value not only in etiology and diagnosis, but also in prognosis. These conclusions have, however, not yet met with universal ac- ceptance, as the observations have not been sufficiently verified. Renewed interest attaches to this .bacillus of Afanassieff with the discovery by Griffiths of a ptomaine or toxine in the urine of whooping-cough patients. Griffiths claims to have established the fact experimentally that an absolutely identical toxine is developed by this bacillus. The toxine is not found in any case of normal urine, nor in that of any other disease than pertussis. There is now scarcely room for doubt that pertussis is a mycosis whose toxines have a special action upon that part of the nervous system which presides over cough — to wit, the centres of the superior laryngeal and vagus nerves. In this way, in our day, the mycotic has displaced the neurotic theory. The contagious principle is not often disseminated without direct 8 114 WHOOPING COUGH. exposure to the disease. Very slight isolation secures exemption from the attack. The bacillus has no great tenacity of life. Whooping cough occurs with special frequency during con- valescence from measles. The disease shows itself also in close relation to tuberculosis. It has long been noticed that tuberculosis often follows close upon the heels of whooping cough. It is impos- sible to say in a given case whether the whooping cough made the soil fertile or merely aroused the latent disease. It is an error to consider whooping cough as a trivial malady. There occurred in England in one year, of 500,341 deaths, 10,318 deaths from whooping cough. In New York in one decade, wherein 4,062 deaths occurred from typhoid fever, there were 4,094 deaths from whooping cough. Hagenbach says that whooping cough had more victims in Basel in fifty years than any disease except typhoid fever and diphtheria. The general mortality is estimated at three to seven per cent. It has reached as high as forty-eight per cent in the second year of life. Symptoms. — The disease begins with the signs of an ordinary catarrh of the exposed mucous membranes. Whooping cough occurs, as stated, in paroxysms or explosions. It would appear as if the nerve centres suddenly discharged them- selves of accumulated irritation, as in a case of epilepsy. Close ob- servation of a case gives rise to the impression that the poison ac- cumulates gradually up to a certain point, when it may be no longer stored and is discharged with the explosion that characterizes a par- oxysm of the disease. Whooping cough is usually divided into three stages : the stage of catarrh, of spasm, and of resolution. The first stage lasts about one week. Sometimes this catarrhal stage is very short, and the spas- modic element manifests itself at the end of the second or third day. Very soon the cough assumes the convulsive character, and sooner or later occurs the typical staccato cough, with the long-drawn, aud- ible inspiration. The second stage has now set in. In these at- tacks the seizure is sudden. Sometimes, though not as a rule, there is a kind of premonition or aura which previous experience has taught the child to recognize. It is usually a sense of impending distress or danger, which leads it to leave its play and run to its parents, or grasp a chair for support. The aura may be in the form of a dyspnoea, a precordial distress, a nausea, sometimes an actual vomiting, whereupon ensues the series of expiratory coughs which distinguish the disease. The breath is lost. The face flushes or be- comes livid. The eyes protrude. Saliva flows from the mouth. The look is wild, bewildered. There is for a few moments the ap- pearance of imminent danger. WHOOPING COUGH. 115 The discharge of the contents of the stomach and a mass of glassy, 'glutinous mucus from the throat closes the attack. But the scene may be repeated once or twice before the last spasm yields. Inspi- ration then becomes quieter, and the child, pale, covered with sweat, exhausted, sometimes almost in collapse, is released until the next attack. Meanwhile it recovers itself entirely, resumes its play, un- mindful of the disease, until it is suddenly seized again. Paroxysms occur in every grade of severity. They are some- times so mild as to make the diagnosis difficult; in other cases so se- vere as to lead to rupture of vessels. Haemorrhages may occur from the nose and mouth. Subconjunctival haemorrhage is not uncommon. The membrana tympani ruptures at times, and free blood appears at the external meatus. Ectatic vessels burst in the skin in the face, in "the cheeks, to show, visible at a distance, subcutaneous extravasated blood. Haemorrhage from the stomach or intestine, or from the kid- neys or bladder, is much more rare. Haemorrhage in the brain, which sometimes occurs, is fortunately very much more rare. Hernia is not uncommon. Convulsions are possible. The duration of an at- tack is usually from a half to two minutes, though it seems to anxious, sympathetic relatives four or five times as long. As the severity stands in quite close relation with the frequency of attacks, it is important that the number be counted, as by a stroke on a piece of paper or a slate, according to the suggestion of Trous- seau. Diminution in the number of attacks is the first sign of approaching relief. Burman attributes the frequency of attack at night to the diminished vigilance of the respiratory centres, retarded and more superficial respiration, and greater accumulation of car- bonic acid gas. About the fourth decade of the present century attention began to be directed to the more or less constant appearance of an ulcer on the framum linguae, due to friction of the protruded tongue against the inferior incisors. It is absent altogether where the attacks are very light, or where the fraenum is short, or the tongue may not be protruded, or where the incisors are dull. It has been seen also independently of whooping cough, in cases of cough from ordinary catarrh, where the lower teeth have been unusually incisive. The spasmodic stage lasts, as a rule, two to four weeks, when the interval between the paroxysms becomes gradually longer and the explosions themselves less severe. Whooping cough is liable to many complications, especially on the part of the respiratory organs. Bronchitis belongs to the disease, and usually drowns all other sounds in the lungs with its rales. Any disease attended with bronchitis is liable also to broncho-pneu- monia, and broncho-pneumonia is the most frequent of the serious 116 WHOOPING COUGH. complications of whooping cough. The spasmodic closure of the glottis and the powerful efforts of the expiratory muscles sometimes develop oedema of the glottis, more frequently emphysema of the lungs. The wonder is that emphysema is not more universal. The occurrence of it is, in fact, an exception. It is usually slight, mar- ginal or peripheral, and is marked by dilatation only of the air cells, whose walls are so resilient as to recover themselves entirely with the relief of the strain on cessation of the disease. Sometimes, how- ever, especially in cases of failing nutrition, tuberculosis, syphilis,, and rickets, the dividing walls are broken and air cells are ruptured. Still more rarely air may escape into the pleural sac to constitute a ^pneumothorax, or break the lung at its hilus, reach the mediastinum,. or escape into the subcutaneous connective tissue and inflate, literally blow up, the upper half of the body. There is no better proof of the strength of the heart than the fact that it escapes damage under the spasm and stasis of whooping cough. Complications on the part of the nervous system are very rare. At the height of the attack there is experienced extreme anxiety, a sense of suffocation, a vertiginous bewilderment, approaching loss of consciousness, which disappears entirely with the recovery of the breath. The momentary apncea may be prolonged to the point of danger, and very young children may actually succumb to suffoca- tion. Vomiting, which is usually hailed with pleasure as indicating the end of the attack, may be excessive. It may continue into the interval. It may even produce collapse, or in more protracted form lead to marasmus. More frequently a more or less decided convul- sion ensues, and the case may be marked by a series of convulsions,. any one of which may prove fatal. Sometimes cerebral symptoms continue during the interval, and the case may bear the aspect of a meningitis. Stupor, coma, and hemiplegia would indicate the occur- rence of cerebral haemorrhage. Diagnosis. — The recognition of whooping cough in the convul- sive stage is an easy matter. The series of rapid, sudden, explo- sive, breath-taking coughs, attended by the evidence of venous stasis,. cyanosis (whence the old name blue cough), which ceases only when a quantity of mucus, under the combined efforts of cough, retching, and vomiting, is expelled ; the prolonged expiratory efforts, followed by a long-drawn, audible inspiration, which has been not inaptly- likened to the bray of an ass; and the gradual cessation of the dis- ease, sufficiently characterize it. The prognosis is for the most part entirely favorable.. Notwith- standing the threatened suffocation and tremendous strain upon the heart, recovery is the rule, and that without a trace of lesion. But complications and bad surroundings may intensely exaggerate the WHOOPING COUGH. 117 natural benign prognosis. The prognosis is determined to consider- able extent by the age and sex. The disease is, as stated, from some inexplicable cause, not only more frequent but more severe in the female sex. It becomes less and less grave with advancing life. Majer declares that ninety-seven per cent of all the fatal cases occur under the age of five ; fifty-eight per cent in the first year. Biermer made a grand average of the established mortality rate, based upon the statistics of many authors, at 7. 6 per cent, a figure that certainly entitles the disease to respect. The most frequent causes of death are: 1, suffocation from spasm of the glottis; 2, broncho-pneumonia; 3, haemorrhage; 1, marasmus. The prognosis is grave where the attacks reach fifty in the course •of twenty-four hours; at sixty it assumes special gravity. Individual attacks may do damage also by their intensit}"; thus haemorrhage may be copious from mucous surfaces. Blindness occurs occasionally, probably from oedema of -the brain. Prophylaxis. — As the disease has, at least at times, such grav- ity, prophylaxis assumes importance. The only prophylaxis worthy of the name is isolation. The patient must be separated, not only from children, but from adults who come in contact with unaf- fected members of the family. As this isolation, in a disease which is usually considered so mild, is practically impossible, attention should be directed rather to the protection of delicate members of the family ; they should be isolated. It is advisable that tuber- culous, rachitic, syphilitic, or otherwise diseased or debilitated chil- dren should be removed from the house as early as possible. The most essential element in prophylaxis at all times is the de- struction of the sputum. Though the individual is attacked with the suddenness of an explosion, mucus, at least in quantities, is not ■expelled until the attack has spent itself, so that there is, for the most part, time for the collection of sputum in water. As in tuber- culosis, the handkerchief should never be used for the reception of sputum. Treatment, — The older writers used the anodynes early. Opium, in some form or other, was the shield which was soon interposed. In more modern times the active principle of opium, morphia, was, and is still, extensively employed. With the morphia are often combined five- to ten-grain doses of the bromide of sodium or potas- sium, or there may be added the hydrochlorate of apomorphia. The remedies commonly employed in the treatment of bronchitis are also frequently resorted to. The syrup, simple or compound, of ipecac, one-half to one teaspoonful ; the wine of ipecac in half these doses ; minute doses of antimony, one- sixty-fourth to one-thirty-second of a grain ; belladonna, one drop of the tincture for each year of life ; 118 INFLUENZA. or atropine, one grain to one ounce of water, given in doses of front one to two drops two or three times a day. The iodide of potassium is a remedy of value. It may be given as follows : 5 Potassii iodidi § ss. Aqua3 menthse piperita fl. § ss. M. Sig. Two to five drops in a dessertspoonful of milk three or four times a day. Excessive vomiting may be relieved by chloral, gr. ii.-v. Mild cases are best let alone. Bad cases call for control by opium. Change of climate is the only remedy which does really sometimes "act like magic." ^ INFLUENZA. Influenza; la grippe; the grip. — An acute infection caused by a specific bacillus and characterized by catarrhal, gastric, and nerv- ous signs. Influenza has the same origin as catarrh, rheumatism, etc. — dis- eases derived from the Greek word meaning a flow or flux — but differs from these diseases in the fact that its origin came not from within but from without. It was derived, in the most ancient times, from extraneous influence. It was the "influence" of the stars or of the weather, mysterious telluric influence, that constituted influenza — an Italian word. Influenza takes the front rank among the acute infections on ac- count of its extent. It surpasses all other diseases in its range, in that it often covers the entire globe. It is the type of the pandemic diseases. It never attacks solely individuals, but always communi- ties, peoples, hemispheres. History. — Accounts of it date from the earliest times, and when first seen its universal distribution was appreciated. It was cer- tainly recognized as early as 1173 in Italy, Germany, and England. It prevailed as a true pandemic from 1510 on, at different periods,, with intervals ranging from forty to one hundred years. It showed itself in our own country first in 1627 in Massachusetts and Con- necticut, and extended to the West Indies and South America as far as Chili, and it reappeared again and again with us, at varying inter- vals of five to fifty years, without any distinct periodicity, up to the present time. It is established of influenza, in a general way, that it originates in the East and extends over the "West. Thus the most recent epidemic that has visited our country was first recognized in Bokhara in May, 1890. It reached St. Petersburg in October, Ber- lin in November, London in December, and by the middle of Decem- ber showed itself in individual cases in Philadelphia and New York r whence it gradually extended over the United States, to appear in Mexico in the following spring. INFLUENZA. 119 Etiology. — The first cases of influenza are usually unrecognized. The individuals affected are said to be attacked with a bad cold, or nervous phenomena are interpreted as signs of other diseases, typhoid fever, etc. It is only when individual cases multiply that the poison accumulates to sufficient extent to strike the masses, and this fact has led to the belief in the sudden appearance of epidemics. Influenza is spread hj human intercourse. It follows the line of travel, and extends with the transportation of individuals by river and rail, with the velocity in our clay that corresponds to the rapidity of modern transit. Having traversed a country and gone beyond it, it is liable to return and reappear, especially among individuals previously spared, and thus the disease hovers about a country for a period of months, sometimes years, before it entirely disappears. The cause is in the air. Crews of ships have been seized in the open sea. The fleet under Admiral Kempenfeld had to put into harbor in the second week at sea, having had in the meantime no connection with, the land; and this observation has been repeatedly made. Hermits are said to have been attacked in the woods, or in the caves of their isolated homes. Influenza travels against the wind as well as with it, and is totally independent of climate, season, or soil. It is difficult to fix the place amongst the acute infections where influenza belongs. Whether it shall be considered a miasmatic or a contagious disease will depend altogether upon what is meant by these terms. Advo- cates of miasm contend that the disease originates de novo, or that it is carried by the wind, and meet the objection that it is often carried against the wind by the assumption that the wind at greater altitudes moves in a different direction. We are, however, little concerned with the direction of the upper strata of the air. The wind at high altitudes is more liable to blow down the castles we build in the air than to affect the habitations in which we live. It is observed of influenza that it shows itself first along the lines of river and rail, and that it appears first in towns about railroad sta- tions, later in places removed from the lines of travel. Pfeiffer (1892) discovered the micro-organisms of influenza as bacilli in the pus cells of tracheal mucus. They are minute structures, about the breadth and half the length of the bacilli of mouse septicaemia. They are best displayed with the dilute Ziehl or in the hot Loffler methylene solu- tion. They are immobile in hanging drops. The bacilli of influ- enza form colonies on one and a half per cent sugar agar, visible only with a lens, in drops as clear as water. An absolutely dis- tinctive feature, according to Kitasato, is the fact that these drops ahvays remain apart; they never coalesce. The bacilli penetrate the peribronchial tissue to reach the surface of the pleura. Canon, in 120 INFLUENZA. the same year, demonstrated the bacillus in the blood itself. Toxines from these micro-organisms develop the complications and sequelae — endocarditis, nephritis, etc. — of the disease. No period of life is exempt, though infancy is comparatively rarely attacked. The greatest liability ranges from twenty to thirty. The period of danger is in advanced life. The incubation is short, Wo to three days. In most cases the onset is sudden. Symptoms. — Prodromata, when they exist in the exceptional cases, consist of malaise, languor, headache, light catarrh. The disease sets in, as a rule, suddenly — a fact of value in a diagnostic way— and dis- tinguishes itself in its course by three sets of symptoms, to wit, the catarrhal, gastric, and nervous. Epidemics vary greatly with re- ference to the intensity or predominance of individual symptoms. Individual cases vary in still greater degree. It is, however, the co- incidence of symptoms on the part of these various organs which estab- lishes the nature of influenza and distinguishes it from other -catar- rhal affections. The catarrhal symptoms may affect any part of the respiratory tract; i.e., there may be cor yza, irritation, burning, dry- ness, or discharge from the nose, sneezing, hyperesthesia of the conjunctiva, photophobia, or catarrhal affection of the throat which may not be distinguished from a simple angina. There is much more commonly catarrh of the bronchial mucous membrane. The bronchitis of influenza distinguishes itself by its universality. It is a bilateral affection. It shows great disposition to extend to and involve the capillary bronchi, whence the liability to, and danger of, catarrhal pneumonia. There is corresponding oppression about the chest, difficulty of breathing, precordial anxiety. The gastric symptoms are more marked in childhood. The disease is often announced in children by vomiting, and cases have been reported in which the severity of the vomiting has excited the suspi- cion of the development of scarlet fever, cerebro-spinal meningitis, or pneumonia. As a rule, however, gastric symptoms are marked' rather by anorexia, sometimes nausea, dyspepsia, more especially duodenal catarrh with a light icterus manifest in the tint of the conjunctiva. Exceptional cases show diarrhoea, or even bloody dis- charges. It is the third set of symptoms — the nervous symptoms — which more especially distinguish influenza from other catarrhal affections and give it its specific place as distinct from common catarrh. There is headache, some of which may be accounted for by catarrh in the frontal sinuses, most of which, however, is toxic. There is supra-orbital neuralgia. The headache is frontal, more rarely oc- cipital. Neuralgic pains wander about the body. Patients com- plain especially, often bitterly, of deep-seated muscle and bone INFLUENZA. 121 jjains. There is with these pains great depression of spirits, something more than the mere hebetude of the inception of typhoid fever. These sinking sensations, which take the interest out of and create a disgust for life, characterize well-marked cases of in- fluenza. In exceptional cases nervous symptoms of graver charac- ter occur. The disease may be announced in a child in epileptiform convulsions. Various paralyses, chorea, tetanus, psychoses have been noticed in different cases. A patient may be affected with in- somnia for a week. Roger reported the case of a lady who slept for over a week. Da Costa mentioned the case of a woman, of great delicacy and refinement, who greeted the appearance of the physician with blasphemy. Influenza calls out latent diseases. This is especially true of tu- berculosis. Many cases date the origin of their various diseases to an attack of grippe. " I was all right until I had the grippe, " is a common observation : and while it is possible here to confound with influenza the symptoms of individual diseases, as of tuberculosis or pneumonia, it remains true that influenza is a common exciting cause of these affections. Diagnosis.— The three sets of symptoms — catarrhal, gastric, nervous — distinguish the disease. Influenza is overlooked or misin- terpreted only in the beginning of an epidemic when the cases are few. The predominance of nervous distress, more especially nervous depression and dejection, is a characteristic feature of the disease. Prophylaxis. — According to observations Goldschmidt. of Ma- deira, made in the presence of both diseases as epidemics, revaccina- tion with vaccine virus protects not only against variola, but also against influenza. This statement needs verification. The prognosis of influenza itself is good ; the mortality is almost nil, but the fraction of one per cent — Lynrote says 0.25. Lee reports 1,120,000 cases in Pennsylvania in the last epidemic, with 7,780 deaths, or 1 in li'2 cases. Nevertheless, the occurrence of influenza is a serious thing. It calls out, as has been stated, latent diseases. It aggravates the progress of all diseases in course and terminates many fatally. The disease assumes special gravity in age. It is difficult for an aged person to escape an attack of influenza with good health. It is the indirect cause of death in many of these cases — indirect through catarrhal pneumonia or heart failure. So the death list is duplicated through the prevalence of pneumonia ; and while it is true that the mortality fist at the end of the year is not sensibly increased by the occurrence of an epidemic of influenza, it makes a great difference in a community whether these deaths be diluted through a period of months or years or be concentrated upon a few weeks. 122 HAY FEVER. The treatment is now nearly specific. To meet individual symp- toms and sustain the patient for three to five days constitutes the rational therapy of influenza. A most essential factor is rest. All patients affected with influenza should observe quiet and repose of mind and body in a properly ventilated and warm room. Fever seldom calls for treatment. The temperature rarely rises- above 101° or 102°, and when excessive is best met by sponge baths. The pain is best relieved by broken doses of Dover's powder, or, in the presence of much nausea, by phenacetin. Phenacetin may be given in a single dose of ten grains to an adult to secure a peaceful sleep. Caution must be entered against the abuse of any antipy- retic. Where there is much debility from age or heart weakness, quinine may take its place. The salicylates have something of a specific influence in relief of the symptoms of influenza. Choice may be had as between salicin, salol, and salicylate of soda. All these agents, however, have a sensible though slight effect in de- pressing the circulation, and should be administered in conjunction with a stimulant, a glass of wine or a dessertspoonful or tablespoon- f ul of whiskey. A good salicylate in the treatment of influenza is the salicylate of cinchonidia. Support of the Peruvian bark principle counteracts the depression of the salicylic acid. It is bitter and in- soluble, and hence should be given in capsule or pill in dose of two to five grains every two to four hours. The best single remedy is salipyrin, which may be given in powder or wafer in the dose of grs. x.-xv. every two to four hours. Salipyrin is almost a specific in the treatment of influenza. During the attack all patients should remain at home at rest, and in convalescence should expose them- selves with caution. HAY FEVER. Hay fever ; hay asthma ; catarrhus cestivus, summer catarrh ; June cold. — Catarrh of the mucous membrane of the eyes and air passages, produced only in sensitive subjects, by pollen, hence periodic in recurrence and protracted in duration. History. — The disease is modern not only in recognition, but actu- ally in origin. It was first announced by Bostock (1819) asa" period- ical affection of the eyes and chest," based on personal experience. Elliot son (1839) pointed to pollen as the probable cause of the disease. Helmholtz, also a sufferer, ascribed it to vibrios and lauded quinine by insufflation in its relief. Blackley (1873), another victim, proved pollen to be the true materies morbi. Beard (1876) laid stress upon the neurotic temperament which constitutes the susceptibility to the disease. The condition of the nasal passages themselves, as consti- tuting susceptibility, is a contribution of the last decade. HAY FEVER. 123 Etiology. — Hay fever is a rare disease. It demands a peculiar susceptibility or idiosyncrasy, as, of the millions exposed, but very few are attacked. It is almost confined to the Anglo-Saxon race, and follows it in foreign lands, as in Asia and Africa, where the dis- ease is unknown to the natives. It spares foreigners for the most part in England and America. It shows predilection for males in the ratio of 2:1, probably because of their greater out-door ex- posure. It shows preference also for the upper classes, especially for the clerical avocations. It attacks maturity up to forty, only very exceptionally youth or age. The liability is transmitted by heredity ; and whether inherited or acquired, once developed the disease recurs with great regularity or periodicity about the same time every year. Certain cases have anatomical foundation in the condition of the nose, in occlusions, hypertrophies, polypi, sensitive areas, etc. Pollen is the chief if not the only cause. Blackley proved by ex- perimentation upon himself and others that the disease was caused by pollen, aggravated by greater exposure and limited by less, as by active movements out-doors or quiet within. The pollen of many plants will produce it. That of the graminacese causes ninety-five per cent of cases. Wyman ascribed most of the cases in America to the wormwood, which blooms in August and September. The pollen of plants in blossom often fills the air, is wafted at times to great distances, many miles, to be deposited, sometimes visibly, on roads and streets, where it may appear like sulphur. Symptoms. — Hay fever begins, as a rule, suddenly, at or about the day it is due — wherein it may be helped by a lively imagination — as a coryza or an asthma. The disease shows itself in two forms, ca- tarrhal 'and asthmatic. These forms may follow each other or co- exist. In the catarrhal form there is coryza. The conjunctivae are inflamed, the eyes burn, and hot tears run over upon the face. There is photophobia and headache. The nose itches and burns. There is sneezing, sometimes violent and persistent. The whole tract of the nose is blocked by cedematous swelling, often of rapid onset, of the entire mucosa, The voice is nasal. The inflammation extends to the throat, which is also red and dry, with sensations of rawness and actual pain. In the asthmatic form there is sudden, oppressive, and persistent dyspnoea. Wheezing sounds pervade the entire chest. With this distress there is the depression of spirits and disinclination or ac- tual incapacity for effort which belongs to true asthma. The diagnosis depends upon the recurrence — periodic — in sum- mer, and persistence throughout the exposure. The pjrognosis is good, quoad vitam ; bad, quoad valetudinem. 124 PNEUMONIA. The disease subsides to leave no trace, but recurs every year and lasts for weeks or months. The treatment is addressed to the temperament or tendency, with the administration of, especially, arsenic, which, in the form of the liquor potassse arsenitis, is given in doses of gtt. ii.-v. ter in die to tolerance. The remedy should be begun before the attack. Qui- nine ranks next in dose of gr. v. twice a day, morning and eve- ning. During the attack some relief may be obtained with solutions of cocaine, four to ten per cent, applied with a brush or by insuffla- tion. Unfortunately such relief is too temporary to be of much value. The insufflation of an ointment of boric acid and vaseline, * gr. xv. to 3 ss. , soothes the irritated nasal membrane. Intense conjunctivitis may be relieved by the instillation of a solution of cocaine, four per cent, or of morphia gr. iv. to aqua destillata § ss. Gargles of potassii chloras, or internal exhibition of the solutio saturata, 3 i. every two hours, help the throat. Chloral in small doses, gr. v., may relieve the asthma. It is common practice to administer the iodides in this as in other asthmas, being careful to avoid iodism. Belladonna generally does more harm than good. Morphine in small dose, gr ^ - -g-, is sometimes indis- pensable. Phenacetin or the salicylates relieve the headache and the fever. Patients should stay in-doors and keep quiet. The only radical relief is change of climate — i.e., sojourn in some place dis- tant from the cause, as at the White Mountains, Fire Island, etc. But individual cases yield to surgical treatment, the application of the galvano-cautery, chromic acid, trichloracetic acid, etc., after cocaine. PNEUMONIA. Pneumonia (nvsviiovia, nvev jj.gov ? the lungs) ; fibrinous, lobar, genuine pneumonia. — An ubiquitous, non-contagious, acute, general infection, with its main local expression in the lungs ; caused by a dip- lococcus ; characterized by high fever, pain in the side, cough with expectoration of a glutinous, rusty-colored sputum, consolidation of the lungs with coagulated blood, and resolution in five to nine days with restitutio ad integrum. History. — Pneumonia was known as such and as peripneumonia by Hippocrates, though not separably, in antiquity, from pleurisy and other painful affections of the lungs. Even Sydenham (1670) failed to distinguish between pneumonia and pleurisy. The gross anatomy was first described by Morgagni (1761). Pneumonia was separated into the three well-known stages, congestion, hepatization, and sup- puration or resolution, by Laennec (1819), by whom the disease was first recognized in life ; the lesion (croupous exudation) was first PNEUMONIA. 125 accurately described by Rokitansky (1841) ; the physical signs and diagnosis were definitely established by his contemporary and col- league, Skoda. Acute croupous or fibrinous is so-called from its exudation ; lobar, from its extent ; genuine, in distinction from catar- rhal, hypostatic, metastatic, etc., forms of pneumonia. Etiology. — Pneumonia, in all time limited as a local disease, "the type of the acute inflammations," was finally evolved as an acute, general infection, with main local expression in the lungs, by Jurgensen (1872); a pathogenic micro-organism discovered by Fried- lander (1883), and more conclusively demonstrated by A. Frankel (1886). The frequency of pneumonia is evidenced by the fact that it constitutes three per cent of all diseases and six per cent of all internal diseases ; its gravity by the fact that it causes 6.G per cent of the total mortality and 12.7 of the mortality of internal diseases, ranking thus in frequency and gravity next to tuberculosis. The disease occurs at all ages — three-fifths of the cases before the age of fifteen ; and at all seasons — two-thirds of cases in spring and winter (minimum, September to November), with predilection for feeble constitutions and in-door life. Sinking subsoil water releases soil bacteria ; rain- fall by precipitation frees the air. The history of seven hundred and fifty cases examined by Diet! showed previous perfect health in but eighteen per cent. Contrary to common belief, pneumonia is not contracted by trauma or by taking cold. Trauma may produce an inflammation of the lungs, but not a croupous pneumonia. Under trauma are included inhalations of dust. Thus the percentage of cases among coal merchants not especially exposed to dust is 14.4; among coal miners, working in almost suffocating dust, but 4.7. Ex- cessive use or straining of the lungs, as in playing wind instruments, crying vocations, etc., do not predispose to attack. Regarding ' ' cold " it may be said that over eighty per cent of individuals at- tacked can recall no exposure in explanation of the origin of the dis- ease. Soldiers are attacked in garrison life, seldom during field service ; sailors ashore or when near the coast, seldom upon the open sea. Deaths from pneumonia among the nuns of Paris amounted to 7.02 per one thousand; among washerwomen, 3.05. Among six hundred and seventy laborers constantly exposed to cold and wet, engaged in loading vessels, Parent-du-Chatelet found but one case of " congestion of the lungs " Prisoners and factory girls furnish a large contingent of cases. The ratio of deaths among deni- zens of cities and the country is as 5 : 2. Cold and trauma may, how- ever, act exceptionally as exciting or localizing causes in cases where the real cause pre-exists in the body, just as injuries to the skull and spine may localize abscess of the brain and caries of the spine, or measles excite tuberculosis. 126 PNEUMONIA. f Fig. 89.— Pneumococcus of Friedlander; oval cells with gelatinous envelope. It was the recognition of these facts, together with the observations that the disease (1) has different temporal and spatial relations from affections commonly ascribed to taking cold ; (2) that other organs besides the lungs — notably the heart, brain, kid- neys, and spleen — are often also involved ; (3) that the general symptoms, fever, prostration, gastro-intestinal signs, etc., do not, by any means, of necessity correspond with the extent of invasion of the lungs, which should be the case in a local disease (i.e., slight invasion of ten shows grave symptoms, and vice versa) ; fin- ally, (4) that the disease runs a specific course, terminating at a definite period, after the manner of most of the acute infections — which led Jurgensen, a close, keen, and critical observer, to anticipate the disclosures by the bacteriologists of the real cause of the disease in certain definite micro-organisms. Bacteriology. — Of the various micro-organisms found in pneumonia, two have been finally elimi- nated as pathogenic — viz., the pneumococcus of Friedlander and the diplococcus of Frankel. Fried- lander and Frobenius described as " pneumococcus " certain micro-organisms discovered in sections of hepatized lung tissue, in the alveolar exudation, and later in the rusty sputum. These micro-organisms could be cultivated and inoculated to produce the disease. Inspected in hanging drops they are seen to be thicker in one diameter, hence to constitute really very short bacilli. As found in the body they are enveloped in a distinct capsule which encloses, as a rule, but one, exceptionally two or more elements. They belong to the class of facultative anaerobes ; thrive, hence, without oxygen. They are motion- less. In staining, the capsule remains uncolored. They do not fluidify gelatin, and develop in the test tube in the form of a nail with a thick head. They thrive upon agar and luxuriate upon the potato. They are found in but 5.5 per cent of cases. It is now established that the true pathogenic micro-organism of pneumonia, found almost universally in typical cases — ninety-two per ■ cent of cases (Weichselbaum) — is the " diplococcus " of Frankel (first . seen and described by Sternberg), which is closely allied to the pneu- Fig. 90. — Pneumo- coccus of Friedlander; stick culture in gela- tin, nail shape. PNEUMONIA. 127 '• - mococcus of Fried! ander. This coccus is also, strictly speaking, a ba- cillus, with one end pointed — " lancet-shaped " (see Frontispiece, Fig. 6). It is found in pairs, whence the name; sometimes in rows or beads of five or six or more elements ; is also encapsulated in the body, but never out of it as in cultures. It differs from the pneumococcus in admitting of double coloration, and in not being decolorized by Gram's method. It grows with difficulty upon gelatin, thrives upon agar and in bouillon. Injected into the blood of rabbits and guinea- pigs, it produces septicaemia, which is fatal in twenty-four to forty- eight hours. Introduced directly into the lungs of rabbits, mice, guinea-pigs, and dogs, it produces intense inflammation of the pleura with condensation of the lung tissue, identical with the lobar pneu- monia of man. A peculiarity of this micro-organism is the rapidity with which it loses its virulence in four to five days. Successive cultivations with every precaution show loss of infecting properties, which can be maintained .only by return to the animal body every ten days. Heat at- tenuates and finally abstracts the infectious principle, and thus the diplococcus becomes attenuated in a few days at 41° C. and in- nocuous in twenty-four hours at 42° C. These diplococci have been found in the dust of the floors of houses, as also in the saliva of healthy individuals, as have, how- ever, other pathogenic micro-organisms, Staphylococcus aureus, actinomyces, etc. The avenue of entrance into the body is not definitely estab- lished. It has wide distribution in the body : throat, ear, meninges, joints, kidneys, pleura, peritoneum, etc. Inhalation experiments do not furnish uniform results. Entering the lungs, it excites in these organs specific inflammation, attended by hyperemia and hepatiza- tion, to be followed by fatty and mucous degeneration and the stage of resolution. From the lungs or other portal it enters the blood, in which it has been occasionally detected, to lodge by preference, in individual cases, in the spleen, kidneys, endocardium, and membranes of the brain, etc. Whether the inflammation in these organs depends in all cases upon the diplococcus of pneumonia or upon other secondary invasions, as of streptococci, staphylococci, etc. , remains as yet undetermined. The differentiation of the diplo- coccus from the pathogenic streptococcus is often very difficult. The short duration of the disease corresponds with the short life or infectiousness of the diplococci. They evolve products, antitox- ines, fatal to their growth. Phagocytic processes not yet dem- onstrated of these micro-organisms do not need to be invoked to ® ® & Fig. 91.— Diplococcus pneumo- niae (Frankel-Weichselbaum) : a, lancet shape ; 6, in gelatinous envelope; c, d, in rows and beads. 128 PNEUMONIA. account for the duration or the recovery from the disease. Irregular, secondary, and complicated cases of pneumonia may be produced or explained by invasion of other bacteria, as by the streptococcus, staphylococcus, other diplococcus, typhoid bacillus, etc., all of which may undoubtedly produce inflammation of the lungs. Symptoms. — Pneumonia begins, as a rule, suddenly, without pre- monition or prodromata, which may, however, occur in less than one-fourth of cases. Thus malaise, wandering pains, and distur- bance of digestion may precede an attack of the disease one or two days. Pneumonia is generally announced by a violent chill, often at night, the severity of which is equalled only by a sharp attack of * malaria or small- pox. The chill is especially pronounced in adoles- cence or adult life. In infants the onset is marked by coldness of ^® Av ■■■■:■■$ ^ ':'. '/£, .;^>J>WW ^ . m i^ « Fig. 92. Fig. 93. Fig. 92.— Diplo cocci from sputum, acute pneumonia, early stage: a, pus cells, c, diplococci with capsules (Woodhead and Hare). Fig. 93.— Diplococcus of pneumonia in sputum, much more highly magnified. the surface, vomiting, convulsions, or even coma ; in the aged and cachectic the onset of the disease is much more insidious. Fever rises rapidly, reaching its greatest elevation about the third day. The chill and fever are accompanied or quickly followed by sharp pain in the side, due to accompanying pleurisy, for lung tissue itself is not sensitive to pain. Pain is, as a rule, wanting in old people, in whom the disease usually begins more centrally, to ex- tend outward much more gradually. By the second day the fever is high, especially in young patients. In children it not infrequently reaches 105°. In adults 104° represents an average case. The tem- perature is often out of all proportion to the amount of invasion of the lung. It may stand at 105° when the lesion of the lung may be difficult to fix, or may scarcely show itself until the half or whole of PNEUMONIA. 129 the lung is blocked with blood. After the third day the fever begins to show daily remissions, and by the fifth to the seventh day it falls suddenly, especially in the young, reaching the normal degree within thirty-six hours — i.e., by crisis. The "crises" (upivco, to decide) of the older writers were mostly based upon studies of fever in pneumonia. In the majority of cases, however, fever ends rather by a rapid lysis {Xvsiv, to dissolve). Fluctuations occur throughout the disease. Such uniform or sustained elevations as are charac- teristic of typhoid fever are unknown in pneumonia. Crisis is pre- ceded or caused by leukocytosis, which liberates antitoxines. The ratio of white to red corpuscles may be at this time 1 : 60 or 1 : -10 — a valuable prognostic point. The fall of temperature, with general Fig. 91. Fig. 95. perature chart; fibrinous pneumonia; adult; crisis on sixth day. ^mperature chart; fibrinous pneumonia in child; pseudo-crisis on seventh, real y (Eichhorst). of symptoms and resolution of the disease, occurs in 3 per cent of cases before the seventh day, in seventy- >er cent before the ninth day. In advanced age, or cachexia l; age, the fever frequently runs quite a different course, ascent and decline being much more gradual and the course u ,vr "ted. The typical curve is also altered by complica- rapid rise of temperature at the start distinguishes a ty> neumonia from a typical typhoid fever. Cough commences within the first two days, often with the pain. It is due either to associate bronchitis or pleuritis, usually to both. Since some degree of bronchitis is always present, expectoration consists at first of frothy mucus, to assume later a more significant 130 PNEUMONIA. appearance. The sputum becomes thick, viscid, tenacious, adher- ing to the receptacle like glue, even when inverted. About the second or third day, in a large proportion of cases, it has imparted to it a peculiar rusty or brick-dust color, due to admixture of blood corpuscles. This color is not usually present in pneumonia in old age. Pure blood may show itself in streaks, or be itself the sole constituent of sputum. Liquid, black or dark "prune-juice spu- tum," often accompanied by fcetor due to mixed infection, is of grave import as indicating decomposition of the blood. Purulent sputum, which is more common, also proves mixed infection with pyogenic bacteria, but is not of necessity so grave. Respiration is soon increased to 30 to 40 per minute. It is hur- ried, shallow, superficial, and painful — painful because of pleu- risy. It is, as a rule, more rapid in children than in adults ; it may remain unaffected in age. The pulse, 100 to 120, full and bounding at first, becomes later soft and feeble. It is not increased in the same ratio with the respiration. Very early in the progress of the disease the pulse-respiration ratio is disturbed, respiration being hurried out of all proportion to the pulse. Thus the nor- mal ratio, two to nine, or one to four and a half, may become two to four, two to three, or even one to one. The majority of cases show temporary albuminuria, due to retarded circulation during the height of the disease. The chlorides diminish and may be entirely absent from the urine, as is readily shown by the nitrate of silver test. They reappear about or at the time of crisis. This sign has lost much of its former diagnostic and prognostic value since the observation that the same change occurs in the fevers. The presence or absence of chlorides is large refusal or lack of digestion of food. Herpes occurs in about fifty per cent of cases, The ve pear upon the face or exceptionally over the body, prognostic as well as diagnostic significance. It does in typhoid fever. In a large majority of cases in whi pneumonia in well-developed form it foretells recovery TV ance of herpes is more welcome because it shows itself o r about the third day of the disease. Unfortunately it I so often in age. Physical Signs. — Pneumonia picks by preference upon lung, the base rather than the apex. It is bilateral tional cases, and then more especially in drunkards. Pneumonia, ■* Fig. 97.— Diplococcus of here as elsewhere, to neglect of the proper ex- pneumonia in sputum . animation of the lungs. This is especially true regarding the debilitated and aged, and the remark is worthy of re- petition that pneumonia is a disease of age. The greatest number of old people succumb to this disease. The prognosis of pneumonia depends upon three factors — the age, habits, and condition of the heart. In children the prognosis is good, the disease having almost no mortality at this period of life. In ad- vanced age the mortality is estimated as high as sixty per cent. The disease is most fatal of all in drunkards. The existence of a chronic valvular disease of the heart intensely aggravates the prognosis. A pulse over 120 is grave. High fever is an index of gravity. Fen- wick (London Hospital, one thousand cases from 1880 to 1890) found the mortality in direct ratio to the fever. Albuminuria is grave in proportion to its amount. Taking cases as they come, the mortality averages about ten per cent. The disease is, therefore, fully as fatal as typhoid fever with all its complications. It is impossible to speak intelligently of prophylaxis without more definite knowledge of the mode of ingress and action of the cause of the disease. To inure the body by exposure to fresh air and by cold baths, with well- ventilated sleeping apartments, the avoidance of defective hygiene in every way that concerns the habi- 136 PNEUMONIA. tation and the ventilation of the lungs, to protect the heart by avoid- ance of stimulants or mental anxieties, nearly covers the ground. In treatment a case of pneumonia calls for a large, well-venti- lated room. The temperature of the room should not be allowed to rise above 68°, as recorded by a thermometer at the head of the bed. Here it is important to remember and repeat the fact that the disease is not due to taking cold, and that there need be no fear in securing free ventilation. An abundance of pure air is of supreme import- ance in the treatment of this disease of the lungs. The respiratory centres are best stimulated, in the presence of high fever, with cold baths, or with baths which may begin at moderate temperatures ^and be gradually reduced. Where for any reason baths are imprac- ticable, they may be substituted with an occasional dose of quinine or phenacetin. There is seldom call for the treatment of fever in pneumonia. Cough does not often demand special treatment. Any excess of cough may be best relieved by Dover's powder gr. ij. or iij., or apomorphia gr. tY~tV< or the syrup of senega 1 drachm every two to four or six hours. Small doses of morphia, gr. ^ in cherry- laurel water or peppermint water, are most efficacious. Morphia also best relieves pain, and, by permitting deeper respiration, best prevents oedema of the lungs and protects the brain. Poultices or other external applications to the chest are of no value except in re- lief of pleuritic pain. Dry cups will drain an inflamed pleura, an ice bag sometimes gives intense relief, but morphia, subcutaneously is the sovereign anodyne. Sleeplessness may be met by sulphonal or trional, gr. xv. in hot milk or tea, or by small doses of chloral, the latter always to be preceded by the administration of gtt. x.-xx. of dilute hydrochloric acid, or to be taken in connection with a wineglass- f ul of sherry wine or a dessert- or tablespoonf ul of whiskey. Where the heart is feeble, as in the aged or drunkards, chloral must be ad- ministered with caution and in minimum dose, gr. ij. or iij. In these cases it is often better substituted by morphine, gr. T V - -J-. Any un- due intolerance of the stomach may be brought into subjection by small doses of chloral in peppermint water, or a drop or two of creosote, with the tincture of nux vomica ; or, after failure of these remedies, by rectal injection of the bromide of sodium gr. xxx. or xl.,. chloral gr. v.-xv., or morphia subcutaneously gr. 4---J-. The real danger, as stated, lies with the heart. The best support in ordinary cases is alcohol in the form of whiskey, which may be given to an adult in dessert- to tablespoonful doses every two to four hours. A call for a stronger stimulant may be met with brandy,, with coffee, or both. Cold sponge baths always fortify the heart. Among the drugs the most valuable are caffeine, the soda ben- zoate, two or three grains every two or three hours ; strophanthine TUBERCULOSIS. 137 sparteine, and digitalis. Sparteine and strophanthin may substitute digitalis for a short time in case of great irritability of the stomach. Digitalis is always best when it may be borne. The infusion, fresh, made from the leaves, may be given in the dose of 3 i. to 3 i. every two to four hours, or the tincture, five to ten drops at the same inter- val. The danger of the drug is in tetanizing the heart, which may be avoided by withdrawing the remedy so soon as the hard, wiry, digi- talis pulse begins to be felt. It is wise in all cases to administer some form of alcohol as the patient approaches the crisis, and it is not un- wise to stimulate moderately from the start. Behring, Kitasato, and the Klemperers utilized the antitoxine derived from the blood of immunized animals in prophylaxis and cure of the disease. The antitoxines in the blood serum of man rendered " immune by crisis " — i.e., withdrawn just after the crisis — proved equally effective in the experiments of Xeisser in aborting the disease. Such serum, withdrawn two or three days after the crisis, and injected, one hundred and thirty, seventy, and fifty cubic centimetres respectively, into the arms of patients in the height of the disease, cut it short within twenty-f our hours. TUBERCULOSIS. Tuberculosis is the specific infection produced by tubercles, which are in turn special products of a distinct micro-organism knowm as the Bacillus tuberculosis, or, from its discoverer, Bacillus Kochii. Tubercle is the diminutive of tuber, a nodule, induration, projec- tion mass. Though the word tubercle is as old as anatomy, the term tuberculosis, in designation of a definite disease, is modern. Vir- chow has shown conclusively that tubercle, in its modern specific sense, cannot be found in the works of ancient writers, who used it only to express a morphological meaning. It is difficult to fix the time when the term began, by common consent, to be limited and confined to the special disease, for ,the reason that the distinct isola- tion of the affection is an acquisition of such recent date. But it is safe to say that the day begins with Bayle and Laennec (1810 to 1819) when they declared, with proof, that '•'tubercle is the cause and constitutes the proper anatomical character of pulmonary phthi- sis." As both Bayle and Laennec literally consecrated their lives to the study of this disease, they may be said to have earned the right to make, or rather to fix, its name. The word " tuberculosis " itself was first employed by Schonlein (1839), a disbeliever in the specific character of the disease. Phthisis — literally wasting, consumption — was the Greek name, as an expression of the most prominent symptom of the disease. Phthisis was the term for the wasting disease attended or caused by 138 TUBERCULOSIS. suppurations of the lungs ; it included abscess, gangrene, suppura- tive pneumonias, empyemas, etc. — in short, all varieties of suppura- tive processes. As each of these affections was gradually eliminated and set upon an independent footing, phthisis came to be limited to the condition which, since the days of Laennec, is more properly tnown as pulmonary tuberculosis. The existence of tubercles in the beginning or course of the dis- ease, at some period or place in the body, justifies the adoption of the general name tuberculosis, while the localizations in the lungs, intes- tine, testis, etc., are sufficiently defined as tuberculosis pulmonalis, intestinalis, testis, etc. x The history of tuberculosis falls naturally into five periods, three Fig. 98. —Tubercle bacilli— sputum. •of which, at least, are quite distinct, in that they date from the dis- coveries of distinct individuals — Bayle and Laennec, Viilemin, and Koch. The first is the period of ancient history. During all this period the disease was observed only from a clinical standpoint. The second period, beginning with the birth of anatomy in the sixteenth century, furnishes the first definite knowledge regarding changes or lesions of structure. The third period followed the publication of the discoveries of Bayle and Laennec in the first quarter of the nine- teenth century, declaring tuberculosis a separate affection, due to the deposit of tubercle, a specific product independent of ordinary in- iflammation. This period is made more distinctly memorable by the TUBERCULOSIS. . 139 discovery of auscultation as a means of diagnosis. It was the genius •of Laennec in the discovery of auscultation which first rendered pos- sible a diagnosis of the disease in life. The fourth period was intro- duced late in the last half of the nineteenth century with the inocu- lation experiments of Yillemin (1865) ; and the fifth was announced with the discovery by Koch (1882) of the tubercle bacillus as the de- finite cause of the disease. The discovery of the tubercle bacillus gave the final death-blow to the doctrine that tuberculosis was ever in any sense secondary. The spectre of inflammation, which perpetually stalked to the front to obscure the true nature of the disease, was quieted forever. Fig. 99.— Tubercle bacilli with spores, in sputum. Instead of producing the disease, inflammation is itself relegated to a secondary place in pathology as a mere result of infection. We may epitomize the history of tuberculosis with the statement that it was regarded first as a process of suppuration (pus) ; then as consisting of nodules, which in the third period are seen to be dis- tinct tubercles ; fourthly, these tubercles contain a virus ; and in the final period the virus takes shape in the tubercle bacillus. The tubercle bacillus invades the body through the lungs, in which it produces the disease commonly called consumption ; or, reaching the bronchial glands, is thence disseminated at some future time to the brain (meninges), bones (vertebra?, hip joint, etc.), and •other organs and tissues (larynx, testis, serosa?, etc.), to lead to sepsis and slow marasmus. Introduced into the intestinal canal with 140 TUBERCULOSIS. food (milk), it ulcerates the mucous membrane, to produce diarrhoea,, marasmus, or fatal peritonitis. Tuberculosis in its various forms destroys two-sevenths of mail- kind. Tuberculosis of the lungs alone carries off one-sixth of man- kind and nearly one- third of the working class. Etiology. — The tubercle bacillus is a slender rod whose length is; about one third of the diameter of a red blood corpuscle. It is about five times as long as broad. It varies somewhat in size, but presents such nearly uniform appearance as to be used as a standard of com- parison for other bacilli. It lies usually slightly curved, but is often perfectly straight and uniform throughout its length, except where it is apparently broken by intervening highly refracting spherical spaces, four to eight in number, which are regarded as spores. Bacilli of rapidly developing disease show these spores in greater number.. ^iX ■m ; * life W G \ ■ " -:- , kH. Fig IOC .—Tubercle bacilli in sputum £ * / Fig. 101.— Tubercle bacilli in sputum. In retrograde or quiescent processes they are usually entirely absents The figures show various common pictures of the bacillus, with and! without spores, in the sputum ; also frontispiece, Figs. 10 and 16.. A point of singular interest is the fact that the bacillus is quite as- resistant to heat and destructive agents as the spores themselves. The Bacillus tuberculosis is distinguished by its extreme tenacity of life. It is invested by a membrane so dense as to be almost impene- trable by dyes in long saturation, or by the aid of heat. This very fact, however, which made the bacillus so difficult of detection, led later to its easier recognition ; for the membrane, having once become permeated, retains the color in subsequent attempts at displacement, so that while an original color may be displaced in surrounding ob- jects by a new dye, the bacillus retains its own color, whereby its. presence may be recognized by difference or contrast of color ; color TUBERCULOSIS. 141 Fig. 102.— Tubercle bacilli in sputum. "being more obtrusive than shape. Colonies cultivated with difficulty appear as scales upon the surface of the soil selected, usually gelatin- ized blood, and do not invade the substance of the soil. What is the original source of the Bacillus tuberculosis? All that is known is that it has come down to us. from the older civilizations. The Indians of our own country, the ne- groes of Central Africa, the inhabi- tants of islands of Australasia, never knew tuberculosis until it was brought to them by Europeans. So. too, tuber- culosis was unknown in the Xorth, among the Esquimaux, Laplanders, etc., until they received it by impor- tation. Once received it is propa- gated by direct descent.- Resistant as is the bacillus, so tenacious of life as to be able to live for months outside of the body, it is nevertheless a strict para- site. It may live, but not grow and multiply, out- side of the body. Man, with many other mammals, especially the cow. offers the best soil for the growth and maintenance of the tubercle bacillus, and the disease is spread chiefly by the desiccation and dis- semination of sputum. The sputum is nearly a pure culture of the Bacillus tuberculosis. Diluted 1 : 100,- 000 times, it will still propagate the disease in the bodies of rabbits and guinea-pigs, animals most of all susceptible to the disease. Inoculation is the final test in a doubtful case. The discovery of the fact, made by Koch, that the disease is chiefly conveyed by the dried and disse- minated sputum, -met with remarkable confirmation in the investigations of Cornet. Inasmuch as it had been impossible to discover the tubercle bacillus in the dust-laden atmosphere, or in the dust deposits upon walls, ceilings, furniture, etc., of rooms in- habited by tuberculous patients, Cornet undertook to collect it under every precaution, and to establish its infectiveness by inoculation of guinea-pigs, rab- bits, and other sensitive animals. This experiment succeeded in two-thirds of the cases. It had long been noticed that relatives in close association con- tracted the disease from each other — husbands from wives, wives more especially from husbands because of the closer contact and confine- Fig. 103. —Colonies of tubercle bacillus in scales on surface of blood serum, six weeks old. 142 TUBERCULOSIS. ment in the house. So the disease had been observed to extend through factories and prisons, showing a mortality equal to fifty per cent after a long confinement. It had been remarked, indeed, that confinement to prison for life is condemnation to death by tubercu- losis. Flick called attention to the fact that so many cases occur in individual houses that a house remains a centre of infection for an indefinite time. Seventeen of twenty-two deaths from marasmus and meningitis in children occurred in houses which had been infected by tuberculosis of the lungs and bowels in adults. Niven observed that twenty-six of forty-five cases were contracted in a house where death occurred ; sixteen in houses previously occupied by tuberculous pa- tients. McMullen called attention to the danger of sea voyages with consumptive companions in confined cabins, and the same danger has been remarked, though in less degree, with the discovery of tubercle bacilli in sleeping cars. Individuals who make the beds, dust and sweep rooms of patients are the most exposed. Seventy-three per cent of nurses up to the age of fifty die of tuberculosis. The tenacitj^ of life of the bacillus was demonstrated in one re- markable experiment, where a feather bed upon which a consump- tive lay was sent to five different cleaners in Berlin, and an infusion made of the feathers after its return the last time proved infective to guinea-pigs. The disease, therefore, is chiefly conveyed through the avenue of the lungs. Tuberculosis pulmonum is the common expression. The bacilli, inhaled and inspired everywhere in the bronchial tubes, come to lodge more especially at the apices of the lungs. Received anywhere in the bronchial tubes, they are more readily expelled from the middle and lower regions of the lungs, or are coughed up into the apices — parts furthest removed from the blood supply, regions also more quiet for growth and multiplication. There is no proof that the disease is ever inherited in man, though inheritance is assumed as a potent factor in the transmission of the disease. Thus it is said that of one hundred patients affected with phthisis, twenty-five will have had tuberculous parents ; but if we recall the fact that these one hundred patients had two hundred pa- rents, it will be seen that twenty-five represents heredity in but one- eighth of the cases, whereas we know already that tuberculosis is fatal, in the lungs alone, to one-sixth of all mankind. If the disease were produced by heredity it should appear first in the internal organs — the liver, spleen, the kidneys, etc. It should be discoverable also in the foetus. It is known, however, that tuberculosis appears first in the lungs, and in children only at the end of one or two years of life. Advocates of heredity maintain, to account for the absence of the disease in the new-born child, that the micro-organism is transmitted in the form of spores. The burden of proof rests with TUBERCULOSIS. 143 them. In the meantime it is observed that the disease appears nearly always in the kings, whence it is evident that the cause of it is inhaled from the outside air. But when, in the more exceptional case, tuberculosis affects other, even distant organs, an autopsy reveals the existence, or the evidence of pre-existence, of caseous bron- chial or mesenteric glands as depots or centres of infection. The theory of heredity is dangerous, in that it removes attention from the avoidable sources of the disease. It is unsatisfactory, in that it does not prove enough. It is also undemonstrable : experiments made to prove it are all open to objection. Finally, it is superfluous. Certain individuals are said to be predisposed to tuberculosis. This predisposition is stated to be announced by an elongated, flattened thorax, a long, narrow neck, a thin skin with apparent blue veins, an enfeebled musculature, etc. This condition is de- clared to constitute the phthisical habitus. The truth is, these indi- viduals are already the hosts of the tubercle bacillus and the victims of the disease. Deutsch has shown that there is no predisposition in the configuration of the thorax, and that broad-chested men contract the disease as readily as those with narrow chests. It is claimed that certain catarrhal conditions of the mucous membrane predis- pose to the disease. This may be, but the fact has not been demon- strated. Predisposition is probably largely a matter of quantity or number of bacilli inhaled. Conditions which markedly interfere with the nutrition of the lungs may be admitted to favor the reten- tion and growth of micro-organisms. Thus it has been noticed that individuals in whom the pulmonary artery is small easily become victims to this disease. Congenital stenosis of the pulmonary artery is nearly always attended with or followed by tuberculosis. On the other hand, certain anatomical conditions render an indi- vidual less liable to be attacked. Such conditions as favor venous stasis or hyperemia offer obstacle to the development of tubercu- losis. Thus tuberculosis does not occur, as a rule, in cases of val- vular disease of the heart, asthma, or emphysema. Exceptional cases sometimes admit of explanation. Thus clinicians differ as to the effect of aneurism of the aorta. Aneurism of the aorta, so long* as it causes a venous stasis, interferes with the development of tuberculosis. When it, however, attains such size or disposition as to encroach upon the pulmonary artery, it will favor tuberculosis. There is probably no such thing as an individual predisposition to tuberculosis. A man may have weak lungs, as he may have a weak stomach, weak eyes, or a weak brain. This weakness may be said to constitute a predisposition to disease of any kind, and in this way only may be admitted a predisposition to tuberculosis. Degraded surroundings constitute the chief predisposition to the disease. 144 TUBERCULOSIS. Trudeau showed that infected rabbits confined in dark, damp holes ■speedily succumb, but allowed to run about in the open air recover from the disease. The chief source of infection — by the alimentary canal — occurs through the milk of tuberculous cows. Bollinger showed that milk may be infectious even though the udder show no signs of disease. Ernst and Hirschberger confirmed this fact. Dilution of the milk, which diminishes the relative proportion of bacilli, renders it much less infectious, so that it may be said, as a rule, that milk from a large dairy is not so dangerous as milk from a single tuberculous cow. Cases of infection through mucous membranes or the broken skin are much more rare. Symptoms. — Tuberculosis of the lungs begins, as a rule, insi- diously, and usually in one of three ways : first, as a bronchial catarrh ; second, with general failure of health ; third, as a dys- pepsia. Other individual cases begin with disturbances of men- struation, with metrorrhagia, more especially with chlorosis or amenorrhea. Other cases follow in the wake of a tuberculosis localized elsewhere, as in the bones of the spinal column or the hip. i\ ot infrequently the disease of the lungs lies latent for a time until brought into prominence by some intercurrent affection. Measles and pertussis very frequently awaken tuberculosis. In a more ex- ceptional case the disease appears suddenly as an acute pneumonia, acute pleurisy, a sharp haemorrhage, etc. The majority of cases begin with a bronchial catarrh. These in- dividuals are said to have taken " cold." They are subject to taking cold. On every slight exposure they take cold, and the cold distin- guishes itself by its persistence. They take cold with every change •of weather, with every change of clothing, often without any kind of exposure. The cold becomes more suspicious when the cough which marks it occurs with greater frequency just after retiring, or just after arising in the morning. The change in the blood current is invoked to account for this occurrence. A gradual deterioration of strength, vigor, color, appearance is noticed by relatives and friends. The individual is said to be "fall- ing into a decline." The general degradation of strength and health very often overshadows the cold. Certain poisons are evolved from the soil in which the tubercle bacillus grows to affect the nutrition, to produce dyspepsia. The menses are withheld, delayed, more especially in young girls about the time of puberty. In all these cases the physician entertains first the suspicion of tuberculosis. Pneumonias which are situated at "the apex should more especially excite the suspicion of a tuberculous basis or origin. The pleurisies which are insidious in their develop- TUBERCULOSIS. 145 ment, which are not attended with much pain, but are marked by more profuse effusions, belong to tuberculosis. Bronchial catarrh becomes more significant when associated with physical signs. It must be remembered, however, that there is a. pre-physical stage of tuberculosis, often of months' duration. Sooner or later characteristic signs develop in the chest. These changes can be recognized first by auscultation. The hyperemia of the bronchial walls under the first irritations of tuberculosis roughens the inspiratory sound. The inspiration is said to be rude, like that of a child, puerile. Soon the elasticity of the lung tissue is impaired. It takes the lung a longer time to contract. Hence expi- ration is prolonged. This rudeness of inspiration and prolonga- tion of expiration is observed in its finer shades only by comparison with the sound side. Moist rales develop later, and these moist rales of bronchial catarrh have peculiar significance in their locali- zation. All these signs .point to tuberculosis when they are fixed about the region of the clavicles. As the disease advances these symptoms show themselves in greater intensity. The cough becomes more continuous, it prevents sleep at night, and so harasses the patient during the day as to lead in its violent efforts to vomiting and the loss of food. The cough shows itself in all grades of intensity in different cases, and in the same case at different times. It must be remembered that cough which is attended with expectoration is really salutary. Cough literally expectorates the disease, and it is only when it becomes so severe as to lead to the ejection of food, or so harassing as to pre- vent sleep, that it calls for alleviation. The expectoration becomes now more characteristic. There is ejected along with the frothy mucus more or less solid matter, parti- cles or pellets which are often pure cultures of the tubercle bacillus. The whole mass of the sputum becomes more solid. Expectorated in water, it assumes a more or less globular or coin shape and sinks to the bottom of the vessel. This is the sputum rotundum f nudum petendum of the old writers. The quantity of the sputum varies in every degree in different cases, and in the same case at different times. At times violent efforts secure nothing. Again the sputum is so profuse as to constitute a bronchorrhcea. Many individuals empty cavities in the lungs in the morning upon rising, and then cough no more for hours or even during the day. This is the his- tory of certain cases for months or for years. For the most part the cough varies. In states of fever, along with general dryness of the mucosae, there is little or no expectoration. In apyretic states it is apt to be more profuse. With the extrusion of sputum the true ■character of the disease is disclosed. Whatever doubt existed be- 10 146 TUBERCULOSIS. fore is cleared up with the discovery of the tubercle bacillus or of elastic tissue. Certain cases, as stated, begin with haemorrhage. Many cases show no haemorrhage from beginning to end. Haemorrhage occurs in about half the cases. It alarms the patient at first ; it produces a condition of anxiety and trepidation. This apprehension, however, ceases with its repeated occurrence, so that later it may not excite sufficient alarm to secure the rest requisite for its relief. The haein- orrhage does a good turn at times in beginning cases by impressing upon the individual the nature of his case and enforcing the neces<- sity of treatment. Haemorrhage is rarely profuse. It shows itself, ^ as a rule, after or in association with a light degree of fever. Cer- tain cases become conscious of it only on awakening. The pillow or clothing is stained with blood ; the taste in the mouth attracts attention. For the most part it is accidentally discovered as it is received in a vessel. In exceptional cases the patient is suffocated in his own blood ; the haemorrhage is so profuse as to inundate the trachea. Other exceptional cases where the haemorrhage is abun- dant but not so inundating in character literally die of loss of blood ; but, as a rule, haemorrhage ceases under the rest and light diet of a few days, or is cut short by appropriate treatment, to return or to recur again and again in the history of the case. Haemorrhage is not more common in tuberculosis because the blood vessels are blocked by the advance of the disease. Cases marked by haemorrhage live,, as a rule, as long as those in which there is no haemorrhage. Pain in the chest is a common expression of the disease. Infra- clavicular pain is always suspicious ; it is, as a rule, pleuritic. The pain of intercostal neuralgia from the toxic effect of the disease is common throughout its course. As the disease advances and the lung tissue is encroached upon, the patient becomes more and more short of breath. Dyspnoea be- longs to all more advanced cases, from mechanical reasons, also from marasmus of the heart and muscular failures. There is a dyspnoea which belongs to the earlier history of the disease, when there is no marked consumption of the lung tissue. It is a toxic effect. It belongs, along with the excitability of the heart — erethism mus cordis — in the earlier stages of the disease. The fever continues and becomes absolutely characteristic. Sus- picion of the nature of the disease in its inception is confirmed for the most part by the presence of the fever in the evening. The temperature rises from one-half to two degrees every evening, to subside again toward midnight, to show a normal or even subnormal grade in the morning. High temperatures are preceded by chills, and followed by sweats. Increase in fever marks new invasion by TUBERCULOSIS. 147 the organisms of pus. The chill, fever, and sweat belong to sep- ticaemia. Sometimes the fever is high only at noon. The prognosis is largely determined by the fever. In a con- firmed case the fever rises from the normal grade in the morning to Si!! X liiiHiii m m n ii in mmum BlliHiieHB 18IB8BI88H1 181188111188118 Fig. 104.— Hectic (i.e., septic) fever in tuberculosis. 104:° or 105° in the evening, to fall again the same night, and to* show thus such abrupt elevations and descents as to constitute that Fig. 105.— Phthisical thorax in a girl eighteen years old (Eichhorst). see-saw record characteristic of sepsis. The fever depends not sa much upon the extent of the disease as upon secondary infection by the streptococcus of pus. It does not, therefore, necessarily stand in any connection with the amount or degree of consolidation or 148 TUBERCULOSIS. destruction of lung tissue, though, as a rule, high fever and rapid destruction coincide. The tubercle bacillus grows slowly. The streptococcus may rapidly flood the lungs. Phthisis, as stated, is derived from the Greek word cpQioo, to waste. It has its Latin equivalent in consumptio, and emaciation is the most characteristic feature of the disease. The people speak of an individual who is losing flesh rapidly as going into a decline, meaning thereby a subject of tuberculosis of the lungs. A loss of weight, along with pallor, chlorosis, amenorrhcea, erethism of the heart, dyspnoea upon exercise, slight fever in the evening — these are the symptoms which announce the inception of the disease ; but no one of these symptoms is so obtrusive in its further course as the progressive loss of weight. An individual may lose one-third, even one-half, his weight. The fat entirely disappears. The muscular tissue, the glands, even the bones, the nervous tissue least and last, all suffer loss of weight. Yet during the quiescent periods of tuber- culosis the weight may be re- ^" ~~ ~ T 5 " ' ', ■■*■'.■] gained. Patients may thus in- ,.M crease in weight ten, twenty, or even thirty pounds. An acces- sible scales is a valuable adjunct 5a| in the treatment of tuberculosis. Along with the fever or fol- lowing the fever there is, as a j rule, more or less of a sweating ■* — — - — - — '.'.' — — — — — — J stage. It is noticed in the early ihn i« t lu^i. i * -i ™ a - history of a case of tuberculosis Fig. 106.— Tubercular ulcer of ileum (Med. ana J Surg. Hist, war of Rebellion). that the skin is unnaturally moist. The hands are either dry and hot or moist and hot, clammy. Tuberculous patients are very prone to show discolorations upon the skin, and especially in the region of the sternum, from pityriasis versicolor, fungi which grow in the skin on account of its increased moisture. When sweating becomes pro- fuse it constitutes a feature of the disease, and, inasmuch as it occurs after the fever, it is known as night sweat. Night sweats may be so profuse as to saturate the clothing and bed linen to such an extent that the patient suffers actual cold, and the clothing must be changed in the night. Such sweating is sometimes colliquative. It is a curious fact that these night sweats come and go in the history of a case of tuberculosis under circumstances which do not admit of explanation — that is, they disappear of themselves at times under the same conditions as existed during their appearance. Ap- peal is made in explanation to the action of the sympathetic nervous system, to the effect of septic toxines on sweat-producing centres. Dyspepsia belongs to tuberculosis. Many cases, as remarked, are TUBERCULOSIS. 149 preceded or announced by an obstinate dyspepsia. It is at first due to the poisoning of the blood, later, to some extent, to deglutition of the sputum. It is the history of most cases to show, during the first stage of fever, constipation. Later on, far along, nearly all cases of tuberculosis show diarrhoea. The diarrhoea is due to the direct in- vasion of the mucous membrane by the tubercle bacillus as conveyed to the intestines by the sputum. It is also due to sepsis. The ulcers of tuberculosis are found in great- est abundance in the lowest part of the ileum about the ileo-caecal valve, in the same region as the ulcers in typhoid fever, and for the same reason — that is, that the bacillus received into the upper part is hurried along the alimentary canal under a more rapid peristalsis until it reaches the lower part of the ileum, where move- ment is checked that absorption may take place, and where time and rest are offered for the ac- tion of poisonous matter or poisonous micro- organisms. Ulcers are found in the intestines of tuberculous patients in ninety per cent of cases, and along with these ulcers, in correspon- dence largely with their abundance, diarrhoea, which becomes finally colliquative. Invasion of the larynx is probably always secondary to invasion of the lungs. It is pos- sible to conceive of a primary laryngeal tuber- culosis, and cases have been recorded in which a post-mortem examination has failed to dis- close centres in the lung. We may look, how- ever, with suspicion upon all these cases. Tu- berculosis reaches the body through the lungs, FlG : iw.-Tubercuiar m- » , CT . cers m the larynx and tra- and finds lodgment, if not in the lungs, in the cnea, seen on vertical sec- bronchial glands. Recent investigations show tion j «, deep nicer over the ° . arytenoid cartilage; fr, su- more and more the frequency of involvement perficiai ulcers of trachea of the bronchial glands. It is here that tuber- ( Zie g ler )- culosis sleeps during the quiescent stages of the disease, and hence it irradiates as from a lair. Tuberculosis of the lar} r nx shows no sign at first different from an ordinary catarrh. Later, however, the hypersemia becomes more pronounced, the swelling more intense. Pure cultures are to be seen at times upon the surface, and with the erosion of tissue occur the well-known tuberculous ulcers and deform- ities of the disease. Tuberculous patients very commonly become hoarse of voice ; at times, and not infrequently, aphonic. These conditions are explained by the hyperemia of the mucous membrane 150 TUBERCULOSIS. and the paretic states of the subjacent muscles. Later on the total loss of voice, together with the difficulty in deglutition, is accounted for by the gross destructive change. The tubercle bacilli seem to find a favorable nidus for development in the regions about the larynx, and perhaps there is no place in the body in which they revel in such luxuriant growth. In correspondence with the progress of the disease, with the loss of substance, and the fever, the colliquative night sweats, and diar- rhoea, the patient's strength becomes more and more reduced, the movements of the body more and more confined to the house, to the room, the chair, the sofa, and the bed. This progress may extend ^ over months or years, or over the greater part of a lifetime, with ex- acerbations and remissions, with quiescent stages of months' or of years' duration. During the first stage of the disease the physical signs are few. There is no perceptible limitation to the excursion of the chest. Some degree of emaciation may be remarked. There is no differ- ence in mensuration, and no, or very slight, d inference in percussion. But auscultation reveals the rudeness of inspiration and prolongation of expiration in the early history of the disease. A little later the movements of the chest become more limited and in advanced cases almost annulled. The breathing in these cases is chiefly diaphragm- atic, abdominal. Differences in expansion may be more readily recognized by 'mensuration. All cases of pronounced tuberculosis show a diminu- tion of so-called vital capacity. For practical purposes it may be said that the difference between inspiration and expiration in a man of the stature of five feet eight inches should be three full inches. In tuberculosis this difference is lessened. A difference of but two and a half inches should excite suspicion. A difference below two inches points strongly to the character of the disease. Percussion now shows dulness under the clavicles. Slight shades of difference are recognized best by comparison of one side with the other. Auscul- tation furnishes the evidence of consolidation. There is bronchial respiration, bronchophony, or evidence of pleuritic effusion, or great thickening of the layer of the pleura itself. Inspection shows now marked change in the contours of the chest. The thorax is flattened, the intercostal spaces sunken. The clavicles and scapulae stand out in bold prominence. It is the picture described by Aretaeus. The absorption of fat from the body changes the physiognomy. The features are sunken. A curious condition is noticed in the fingers. The hands themselves become so thin as to be diaphanous, and the absorption of the fat at the ends of the fingers gives rise to that pecu- liar condition called "clubbed." TUBERCULOSIS. 151 Fig. 108.— Shred The diagnosis rests upon the discovery of the bacillus in the spu- tum. When first revealed the disclosure of the bacillus took the time of twenty-four hours to secure saturation with color. Many subse- quent improvements have been made in this original process, so that at the present time the examination occupies scarcely more than fifteen minutes. The most effective means in general use at present is the so-called carbol-fuchsin test : Aquse destillatse one hundred, acidi carbolici crystal, five, alcohol ten, fuchsin one. A particle (of sputum) is placed upon a cover glass, covered and pressed over the whole surface by a similar glass, which is then drawn away. The glass is dried in the air, then drawn thrice, specimen side up, through a flame, whereupon it. is covered by the coloring fluid of elastic tissue in hot, then immersed one minute in the decolorizing spu um ' fluid — viz., water fifty, alcohol thirty, nitric acid twenty — and finally stained with methylene blue. Tubercle bacilli stand out red in a blue field. Masses of sputum should be first boiled with liquor sodse and allowed to deposit sediment over night. While the presence of a single or distinct bacillus would establish the disease, absence of the bacillus does not necessarily ex- clude it, as the specimen examined might not include any bacilli. Re- peated examination may thus be- come necessary. The diagnosis may be established, in a case at all advanced, by the dis- covery in the sputum of elastic tissue. For this examination no particular skill or apparatus is demanded. A morsel of sputum, preferably a gray- ish' or reddish-yellow particle, is pressed upon the slide by the cover glass, to reveal at once, best after the addition of a drop of a thirty-per-cent solution of caustic potash, the curled fibre of elastic tissue, usually, on account of its incompressibility, near the edge of the glass. In all other cases of tuberculosis, of the skin, glands, bones, testis, etc., as well as in all concealed, latent, or quiescent cases, the diag- nosis may be declared in the course of a few days by the subcuta- neous injection of tuberculin — one milligramme of the diluted 1 : 100 solution — which will produce fever in tuberculosis, but will have no effect in other diseases or in health. Fig. 109— Elastic tissue with epithelium and bacteria. 152 TUBERCULOSIS. The prognosis is determined by various factors, chief among- which are the habits of the patient with regard to personal cleanli- ness, especially with regard to destruction of the sputum. Many patients, by neglect of these precautions, live in an atmosphere of tuberculosis of their own creation, so that there is more or less con- tinuous auto-infection. The actual extent of invasion is a factor of importance, but, strange as it may appear, of rather secondary im- portance. A pure atmosphere free from the streptococcus of pus gives the best prognosis. The continued progress of the disease is indicated best by fever, hec- tic. Night sweats furnish signs of more value in a prognostic way ^than the amount of lung tissue invaded. It must always be remem- bered that at any time periods of quiescence may occur, that the dis- ease may be brought to a standstill, that even in conditions of des- perate outlook improvement may take place for a time. The condition of the heart is a factor of value, as indicated by the strength of the pulse. A feeble pulse is a bad omen. The degree of dyspnoea furnishes striking evidence. Superficial, shallow respira- tion indicates rapid advance. Implication of the larynx is a bad sign. Well-marked laryngeal tuberculosis gives the patient not much longer than three to six months to live. Diarrhoea, especially if profuse or obstinate, indicative of more or less extensive ulceration, occurs toward the close of nearly all cases. The signs of marasmus in general, oedema of the feet, vertigo, more or less complete syncope, are ominous signs. Prophylaxis. — From what has been said already, the prevention of tuberculosis resolves itself into a simple problem, to wit, the de- struction of the sputum. True, cases are acquired in other ways, as by the food, milk from tuberculous cows. Tuberculosis may be in- troduced through the skin, but all these other ways are exceptions. The mass of tuberculosis comes through the lungs. It is no longer a question of inheritance. The theory of heredity is, as has been shown, superfluous and injurious. The prevention of the disease, as we know it, in the lungs follows as a matter of course from destruc- tion of the sputum. Cuspidors should stand in every room and hall of houses inhabited by tuberculous patients. The cloths used as handkerchiefs should be burnt before any drying may occur. Pa- tients should expectorate in water, and cuspidors or spit cups should be emptied twice a day. Houses inhabited by tuberculous patients should be subject to sanitary inspection when absolute reliance may not be placed upon the cleanliness of attendants. It is not necessary to isolate tuberculous patients. It is absolutely necessary to remove a child from the breast of a tuberculous mother. It is not necessary to prevent the marriage of tuberculous patients. TUBERCULOSIS. 153 The prevention of tuberculosis depends upon the destruction of the sputum and the thorough boiling — i. e. , sterilization — of milk. AH else is trivial. With these two precautions tuberculosis will practi- cally cease to exist. The radical treatment of tuberculosis implies some address to the destruction of the cause of the disease, or to the rendering of the soil of the body infertile for its growth. Search has been made for a specific ever since the time the disease was known to be a specific affection. So long as it was believed that tuberculosis was only a secondary affection consequent upon other diseases, it was irrational to look for a specific treatment. Chlorine was introduced as a specific in the time of Louis, who found it valueless ; and one substance after another in materia medica, recommended as a specific, weighed in the balance, has been found wanting. All these remedies were empirical. The treatment of tuberculosis up to the present time consisted in climate and cod-liver oil,- with address to symptoms in individual cases. There is unanimity of opinion regarding the value of climate in the therapy of phthisis. Any climate which permits outdoor exercise is of value ; but the value increases with altitude, and in still more marked degree if the altitude be dry. A high, dry air is best suited for phthisical patients. Climatic considerations are best fulfilled in our country in Colorado, at the altitude of about five thousand feet above the sea. Wyoming, Nevada, Montana, New Mexico, all offer points of greater or less elevation, together with the comforts of life — a sine qua non. There is no contra-indication to climate except that which experience may furnish in an individual case. It has been found that cases are less liable to haemorrhage in the altitudes. Cases in which fevers are less marked do the best here as everywhere, and here as everywhere quiescent cases all im- prove. Many, perhaps most, recover absolutely. Latent depots- are often left, to be awakened into renewed activity upon return home. Advanced cases secure the best advantage in milder cli- mates. The islands in the ocean, the Sandwich Islands, the Baha- mas, especially Nassau, the Bermudas, are sojourns at sea without the disadvantages of a ship, which is to most people, as it was to Johnson, ' ' a prison with the additional disadvantage of danger of death by drowning. " Gestation at sea was recommended by Galen. Many cases recover in the longer trips of sailing vessels or in the re- peated voyages of officers, ship surgeons, etc. Mild cases, as stated, are benefited by any change of climate which permits life in the open air. The house climate in which the disease is begotten is inimical to recovery. A high, dry climate acts by increasing the respirations as well as the activity of the heart. The lungs are thus better fed with air and with blood. The air of altitudes is more pure ; it is 154: TUBERCULOSIS. also more dry. There is less self-infection and less infection by sepsis. The products of the disease are more rapidly dissipated. Of all the internal remedies used in the treatment of tuberculosis, but one holds its place as having any real virtue. This remedy is ■creosote. Testimony increases as to the value of creosote. To be effective the remedy must be pure. Impure preparations contain car- bolic acid, which injures the stomach. The patient must be saturated with the drug. Guttmann has shown that the tubercle bacillus will not grow in solutions of creosote 1 : 4000. Such saturation is impos- sible, but large doses are given with the best effect. It is adminis- tered best in mixture with equal parts of tincture of gentian or tinc- ture of nux vomica. The patient may take five drops of this mixture three times a day in an equal number of teaspoonf uls of whiskey and water, equal parts. The creosote mixture is to be increased a drop a day, the whiskey and water a teaspoon a day up to ten, whereupon intermediate doses between meals and bedtime should be commenced and increased likewise up to ten, so that the patient takes finally ten drops in ten teaspoonfuls of whiskey and water six times a day. At this time the body is saturated. Creosote is perceived in the breath, in the exhalations from the skin, etc., and by this time the patient begins to improve. It is astonishing what change takes place in cer- tain cases. It may be said, as a rule, that the afebrile cases do the best, but fever is no contra-indication. In many cases the fever sub- sides ; night sweats cease ; cough disappears ; the patient gains in weight, strength, and spirits. But not in all cases. There are many disappointments. There are cases which gain temporarily, to lose later under continued administration, and there are cases which are not benefited from the start. Harm the remedy cannot do. Cornet believes creosote acts only by improving digestion. Another expla- nation is offered in the neutralization of certain tuberculous toxines, ■or in the aseptic properties of the drug, as its name implies. It is now known that most of the symptoms of tuberculosis are due to -sepsis from mixed infection. Cases in which the remedy irritates the stomach are very few. Exceptional cases may suffer nausea and aversion. In these cases the creosote may be administered mixed with the balsam of tolu in capsules, and gradually increased as before ; or the creosote may be suspended in milk. It is claimed that good effects are obtained by subcutaneous injection of pure creo- sote with pure olive oil, the oil having been rendered aseptic by boiling, in the proportion of one part creosote to three or four parts oil. The first injection may be five drops creosote and fifteen drops oil. The quantity is to be increased to ten or fifteen drops of creosote, with oil in proportion. The injection should be made in the back, twice daily, at a different place each time. It is attended with very TUBERCULOSIS. 155 little pain. Arsenic is the next remedy, because it improves diges- tion and absorption. Tuberculous patients should be fed. Where the stomach is ex- cessively sensitive, milk with equal parts of Selters water, in wine- glassful doses every hour or two, may still be retained. A gentle stimulation may be offered with a light extract of malt, wine whey, Hhine wine, etc. Debove proposed to introduce food in large quan- tities through the stomach tube in the process of sur 'alimentation, and remarkable results were reported from this method. It is as a rule, however, unnecessary, as the appetite may be stimulated and digestion increased by diluted hydrochloric acid, tincture of mix vomica, or liquor potassii arsenitis, so that patients may be made to eat. Buttermilk, sweet-breads, fish, beef — these are the staple arti- cles of diet. Cod-liver oil is now made so pure as to be almost pal- atable. It should be given pure, not in emulsion or mixture, immedi- ately after meals, when the taste is blunted by satiety, in conjunction with or followed by an equal quantity — that is, a teaspoonful to a tablespoonful — of good cognac, ram. or other form of alcohol. The result of treatment by cod-liver oil and alcohol shows how much good can be accomplished by food alone. For with the previ- ous administration of an acid, and the after-administration of a bit- ter, especially strychnia, along with the cod -liver oil, the duration of the life of the consumptive has been fully trebled. In combating the special symptoms the treatment of fever merits the first consideration. We encounter here at once the problem of therapy. A successful treatment of the fever means a successful treatment of the whole disease, and nothing convinces the physician more thoroughly of the futility of radical therapy than the attempt to subdue or keep subdued the fever. The hectic of a day can be held in control by antipyretics, and the fever of the disease may be subdued for several days, or even for a week or two, by the judicious use o'f the milder remedies of this class. Where there is, along with the fever, irritability of the nervous sys- tem, anxiety, and exhaustion, it is best to use phenacetin in two- to five-grain doses three or four times a day, in combination with alco- hol, sherry wine, etc. The excessive fever of the evening may be prevented or subdued by a large dose of quinine, ten grains, three to five hours before the period of maximum temperature, but this remedy gives such distress that it is sooner or later abandoned. Salicylate of soda, salicin, or salol may substitute it in equal dose, or in divided doses, five to ten grains every three to six hours, with perceptible but less marked effect. The salicylates have also their •discomforts, which sooner or later more than compensate for their "virtues ; so that the treatment of the fever of tuberculosis in the long 156 TUBERCULOSIS. run resolves itself into the general treatment of the disease, espe- cially by creosote. Mght sweats, if moderate, may be let alone. They require treat- ment only when profuse enough to require change of clothing in the night or to exhaust the patient. Remedies to control night sweats should be used in the following order : Sponge baths with hot, boil- ing, water. A hot general bath. A solution of atropia, one grain to the ounce ; begin with a dose of three drops ; increase on the fol- lowing nights to four, five, or six drops, or until there is brought about dilation of the pupils or dryness of the throat. Camphoric acid, twenty to thirty grains in capsules at bedtime. Agaric acid or agaricin, one-eighth to one-quarter grain two or three times a day. Chloral, five grains, with a tablespoon of Avhiske} T or a dessertspoon of brandy to counteract its depressing effect. The end will be ac- complished with some one of these remedies. Hemorrhage, if slight, or especially if frequently repeated in the history of the patient, calls for no treatment by drugs. In all cases the patient should go to bed. Hemorrhage demands absolute rest. More continuous or profuse hemorrhage calls for the use of atropia, one grain to the ounce, in dose of two to four drops every two to six hours up to toxic effects. Quinine, in five-grain dose at intervals of two to four hours, subdues the fever upon which the l^peremia and hemoptysis seem at times to depend. An ice bag may be put over the region of the heart to slow down its action. Tincture of aconite in drop dose every hour has been recommended for the same purpose. A persistent haemorrhage calls for the subcutaneous injection of ergotin or sclerotinic acid in half-syringeful doses every half to two hours. Certain individuals learn to check hemorrhage by swallow- ing a teaspoonful of salt, through reflex contraction. Cough in some degree is salutary, for patients literally expectorate the disease with the sputum. Some cough should, therefore, rather be encouraged than checked. ,The cough upon rising is of especial value in this regard. The cough which is so excessive as to lead to the evacuation of the stomach, or so harassing as to prevent sleep at night, calls for treatment. The same remark applies here as to fever, that the radical relief of cough is the cure of the disease. Pa- tients often say, feeling their improvement, if they "could only get rid of the cough " they would be well ; and so they would, but the cure of the cough implies, of course, the cure of the disease. Hence the best remedies for cough are creosote and tuberculin. Cough which begins to be excessive may be relieved by apomor- phia, to which there may be added very small doses of morphia. The bromides, in dose of ten to fifteen grains, may alleviate the cough, as a rule, however, at too much expense to the stomach. TUBERCULOSIS. 157 Chloral in dose of five grains, especially if associated with alcohol, is a safe and pretty sure remedy for the night cough of tuberculosis. It counteracts also night sweats and insomnia. Later it loses its effect. It should never be given in dose sufficient to bewilder the patient or weaken the heart. In the effort to keep away as long as possible from opium, resort may be had to codeia, which may be given, with cherry-laurel water or bitter-almond water, in doses of one-sixteenth to one-eighth or one-quarter of a grain. Sooner or later we must come to morphia. Opium in combination with benzoic acid and camphor, as we find it in paregoric, in fifteen- to thirty-drop doses, may be used at first. Some of the evil of opium is obviated by the use of the deodorized tincture. An intelligent patient in the practice of the author labelled his bottle of laudanum the tincture of hope, on account of the long (years) relief it gave. The fear of the opium habit is not to be con- sidered in this disease. No evil is so great as tuberculosis. The evil is not the fear of the habit, but the disturbance of the digestive system. Opium seems to foster tuberculosis, hence resort is had to the use of it about the time when all hope of recovery is being aban- doned. At the same time it must be admitted that opium with its shield may be called into use earlier since the day of creosote and tuberculin. Opium alone is bad practice. Judiciously employed in connection with attempts at radical relief, it is not bad practice. In gastric catarrh dyspepsia is best avoided or relieved by regula- tion of the diet. Dyspepsia, which precedes the disease for months, is brought under control by diluted hydrochloric acid, ten to fifteen drops in a wineglass of water before meals. A powder of pepsin after meals helps it. A large wineglass of good malt, bitter or sweet according to taste, preferably bitter for most people, also assists it. Let medicated malts be avoided, and let all medicaments be admin- istered separately. The stomach tube should be used early and often. In acute miliary tuberculosis, or .phthisis florida, the stomach must be handled with great care. The patient may take at first equal parts of sweet milk and some alkaline mineral water, at the very first perhaps preferably the German Selters Avater. In spring and summer buttermilk is a most excellent drink ; it is never so good in winter. Sips of water excessively hot relieve nausea and vomiting of most acute infections. Milk may at times be taken boiling hot when ungratefully rejected in any other way. Per contra, certain cases are relieved by cracked ice. lime water and milk, or a pinch of soda in milk. Selters water may be had fresh from siphon bottles ; most of it as we get it is unfit for drink. The diet may be brought up gradually through the soups without fat, and fresh oyster juice, to the white meat of sweat-bread, fish, or fowl. Rare beef should be 158 TUBERCULOSIS. introduced as early as possible in the dietary of phthisis. Eare is as- good as raw beef, and is infinitely more palatable. It may b& chopped fine and made into patties, browned upon the outside. To get the nourishment of beef the meat must be swallowed. Eggs may be used at first only when diluted, as in soups or with hot water or hot milk. Though nutritious, egg in substance is not easily digestible. Vomiting due to indigestible matter is best relieved by washing out the stomach with hot water, preferably with the sto- mach tube. Creosote with tincture of mix vomica is a most valuable remedy in the vomiting of phthisis. Patients under the creosote treatment improve as to the stomach at once. Cherry-laurel water